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HomeMy Public PortalAbout6002 CLOVERLY AVE_Electrical__r _ WORKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT CE-806 ^N� I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY 4 insure, or a certificate of Workers'Compensation Insurance,or , a certified copy thereof(Sec. 3800,Lab. C.) FOR APPLICANT TO FILL IN JOB Policy No. Company EACHN0. FEE ADDRESS New Residential Bldgs. &Pools ❑ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY F1CertifiedSq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAME 4– 4. Date Applicant Outlets: Rec._Light Sw. MAIL q, First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. U.) COMPENSATION INSURANCE 'J PLAN CHECK LL (This section need not be completed if the work involved APPLICANT >_ by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS �r Total No. Additional I certifythat in the CITY Tel No. performance of the work for which this Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any manner PERMIT so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT )� Oven _ Dryer_W.M. ADDRESS 1 Date "J Applicant J, 7 Top _ FAU _W.H. Hood _ Fan _Othe _ CITY - Tel No. Hoor1 f NOTICE TO APPLICANT: If, after making this Certificate of Hoo _ Room Air Cond.—rLICENSE OR Exemption, you should become subject to the Workers' REG. NUMBER Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY with comply with such provisions or this permit shall be Size&Type HP, KW, KVA,or KVAR deemed revoked. Up to 1 Incl I Over 1 to 10 Incl. DATE FINAL A LICENSED CONTRACTORS DECLARATION VALIDATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 ness and Professions Code, and my license is in full force and effect. Services 0-200 Amp. Under 600 V License Number"' �' '` ? Lic. Class 201-1000 Amp. Under 600 V Contractor :_ Date—L—' ! -' k/ Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole & Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits ness and Professions Code): Misc.Conduits& Conductors El 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— structure is not intended or offered for sale (Section 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) I Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE above information is correct.I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE-REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date Y �- WORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT ^l I h'erehy affirmCE-806G that f have a certificate of consent to self CE-806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ❑ 1 & 2-Family, S Ft. $ _ $ LOCALITY Certified copy is filed with.the county building inspec- Y. q tion department. Multi-family Sq. Ft. CROSS ST. NEAREST Date Applicant Residential Swimming Pools OWNER OR ey1 II// FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Recp©�Lightk_Sw.UL MAIL ./ COMPENSATION INSURANCEFirst 20 ADDRESS 1 (This section need not be completed if the work involved by Total No. Additional 0 CITY . �» �5��'�✓ Tel. No."�'� •- the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any manner so as to become subject to the War s'Compens ' n Laws. Lighting Fixtures� First 20 ADDRESS - Total No. Additional CITY Tel. No. Dat App lic nt Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT Exemption, you should become subject to the Workers' Range_ Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood _ Fan _Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. _ Room Air Cond. REG. NUMBER Class. I hereby affirm that I am licensed under provisions of Chapter 9 O}.. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCES BY . and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances `f Q' Size &Type HP, KW, KVA, or KVAR' U License Number Lic. Class U to 1 Incl. FINAL 0 DATE :�/ O Over er 1 to 10 Incl. VA ATION Contractor Date l I Over 10 to 50 Incl. J ❑ FIN Li.t I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 Z Date: Services, Swbd., MCC & Panelboards 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole & Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits 3 3 2 4 A Law fgelhe following reason (Section 7031.5, Business and Protessions Code): #.o o o o o 2 LU I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , I( o o 4 5,0 0 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY 0 00450050 1 hereby affirm that there is a construction lending agency for 0,2 9_8 5 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name �y ` PERMIT ISSUING FEE 6 Lender's Address //�V w Y I certify that I have read this application and state that the TOTAL FEES above information is correct. 1 agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby autho ize"reVr-6T'ntc2NQJ of this County to enter upon the a abgve mentioned property fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee ate J� WORKERSCOMPENSATION DECLARATION 76A66310/81 CE-806G APPLICATION FOR ELECTRICAL PERMIT I-hereby affirm that I have a certificate of consent to self insure, CE-806G ora ceftificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy theredr(Sec.38b0,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS New Residential Bldgs.& Pools ❑ 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. NEAREST % - CROSS ST // Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' ! Outlets:RecALight Sw. MAIL - COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the First 20 Total No. Additional CITY Tel.No. �. permit is for one hundred dollars($100) or less.) �//�/ I certify that in the performance of the work for w it APPILICANT CHECK AY/ ' is issued, I shall not employ any person i manner so as to become subject to the Workers'Comp ation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel.No. Date Applic t lianc NOTICE TO APPLICANT: If, a r mFixed AppNot Over 1 HP PERMIT aking this Certificate of ,/ Exemption,you should become subject to the Workers''Compensation RangeHeater_ D.W.--J/ APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top FAU _ W.H. Hood Fan _ Other_ LICENSED CONTRACTORS DECLARATION _� 1 CITY Tel.No. 1 hereby affirm.that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. LICENSE OR (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER • Class. Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. �j PROCES D BY Size&Type HP,KW,KVA,or KVAR O License Number Lic. Class Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE V Contractor Date Over 10 to 50 Incl. VALI ION o ❑ I am exempt under Sec. Over 50 to 100 Inc. 0 FINAL BY � BAP.C.for this reason Over 100 IL Services, Swbd., MCC& Panelboards ��► 1, N Date: 0- 200 Amp.Under 600 V , �0 0 6.7 A z Signature 201 - 1000 Amp.Under 600 V 0.0 o(o 0 2 Over 1000 Amp.or Over 600 V IleExemption for Reg.Maint.Elect. ° ° 4 a 5 0 SINGLE FAMILY Temp. Power Pole& Appurtenances HOME OWNER-BUILDER DECLARATIONo o a o 4 a 5 0 5 Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits 7 0-1 ,-&8 8 Code I,as owner of the property,will do the work and the structure Misc. Conduits& Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ. C.). PLAN CHECKING FEE Lender's Name [ PERMIT ISSUING FEE � Lender's Address �rI I certify that I have read this application and state that the above TOTAL FEE fi J information is correct. I agree to comply with all County ordinances and State laws re Electrical wiring, and hereby authorize represent of this County o enter upon the above-mentioned pro y for inspect I. r se . SEE REVERSE FOR EXPLANATORY LANGUAGE 7, Of " Signature of Per ittee Date