The URL can be used to link to this page

Home My Public Portal About9467 DAINES DR_Electrical__ WORKERS'COMPENSATION DECLARATION 6q�3 10/811. APPLICATION FOR ELECTRICAL PERMIT � I hereby affirm that I 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 ADDRESS Certified copy is hereby furnished. New'Residential Bldgs. & Pools EACH NO. FEE S Ft. $ — $ LOCALITY L �_ Certified copy is filed with the county building inspec- I &2-Family, q tion department. Multi-family Sq. Ft. CROSS NEAREST ST. Date Applicant Residential Swimming Pools OWNER OR ,s FIRM NAME L CERTIFICATE OF EXEMPTION FROM WORKERS' � MAIL COMPENSATION INSURANCE Outlets: Rec Light Sw. ADDRESS �✓(s ' First 20 p (This section need not be completed if the work involved by TotalNo. Additional i CITY 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 his PPLICANT permit is issued, I shall not employ any perso n any nn r /so as to beco e subject to the Workers'C pen n L s. Lighting Fixtures First 20 �! ADDRESS 4� , 2� fir} Total No. .5* CITY CITY Tel. No. Date ! Applicant - NOT TO APPLICANT: If, after aking this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should bec a subject to the Workers' Range_ Heater_D.W. APPLICANT 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 I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class.. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY and Professions Code,and m license is in full force and effect. Power Apparatus & Large Appliances 1 r y Size &Type HP, KW, KVA, or KVAR ./ O License Number Lic. Class Up to 1 Incl. NNAL V Over 1 to 10 Incl: DAT 7Z � VALIDATION Contractor Date Over 10 to 50 Incl. FIN❑ V I am exempt under Sec. Over 50 to 100 Inc, � Over 100 B.&P.C. for this reason Date: Services, Swbd., MCC&Ponelboards ► 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 7 R I hereby affirm that I am exempt from the Contractor's License , Additional Sign Branch Circuits La for the following reason (Section 7031.5, Business and Pr fessions Code): 3,c.0,° owner of the property, will do the work and the Misc. Conduits & Conductors i o 7 L structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 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 issued. PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name (� PERMIT ISSUING FEE 1/ Lender's Address 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 Stalaws regul ting Electrical wiring, and herby authoriz rese ti, soft aunty to enter upon e above-rrned p 'y for ction p70s SEE REVERSE FOR EXPLANATORY LANGUAGE / d e ot PefThiMee Date WORKERS'COMPENSATIONDECLARATION CE-806G12-80)CE-8APPLICATION FOR ELECTRICAL PERMIT ' - C I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or ° a certified copy thereof(Sec. 3800, Lab. C.) FOR APPLICANT TO FILL IN ,JOB 916 /7 Policy No. Company EACH NO. FEE ADDRESS C�'7 41.�,elr New Residential Bldgs.&Pools 0 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY Multi-family Sq. Ft. — NEARET Certified copy is filed with the county building inspection CROSS SST department. Residential Svvimming Pools OWNER OR FIRM NAME /I/LJS /4�GEf�T/tJ Date Applicant Outlets: Rec.—LightSv MAIL r– First 20 • ADDRESS �f1••!; CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITYTel No. } r�S/�� COMPENSATION INSURANCE PLAN CHECK 0- (This (This section need not be completed if the work involved APPLICANT O by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS U Total No. Cr Additional I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. Q permit is issued, I shall not employ any person in any manner PERMIT U s s to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT W Oven _ Dryer_W.M. ADDRESS N ate Applicant Top _ FAU _W.H.._ Z Hood — Fan _'Other_ CITY Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond._ LICENSE 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 C �7 deemed revoked. Up to 1 Inc[. V 000 Tf FINAL J Over 1 . 10 Incl. DATE t LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. � r VALIDATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINA 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 License Number Lic.Class 0-200 Amp. Under 600 V 201-1000 Amp. Under 600 V L . / n Contractor Date 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 p n sand Professions Code): Misc.Conduits&Conductors 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) Lender's Address PERMIT ISSUING FEE I certify that I have read this_app]ication 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 ounty to enter upon the above-men one prope ty for' sp tion purposes.. SEE'REVERSE FOR EXPLANATORY LANGUAGE Sign "re of Pe ittee V Dat