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HomeMy Public PortalAbout4503 ELLIS LN_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663CE-806G (2-80) n SP IC n N E 201R_ KA S D ERT , .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 `�/t7 �. a certified o y th/�re�(Sec. 3800 •,Lab. 1C.) /d�iyoNo. Company�"� y 317 /�Q�J `y FOR.APPLICANTTO FILL IN JOB Y �- �� oli�y ADDRESS New Residential'Bldgs.&Pools y EACH NO. FEE. //�� �� G .Certified copy is hereby furnished. $ $ LOCALITY �' /�L ��7 � Multi-family Sq. Ft. NEAREST i O Certified copy is-filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR 1 FIRM NAME�'�' Date i®2-- licant - MAIL. Pp Outlets: Rec.— ADDRESS �V� i1t �L First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. J Additional CITY, 6�4Q4�/ L Tel N' . COMPENSATION INSURANCE PLAN CHECK tl APPLICANT < (This section need not be completed if the work involved Lighting Fixtures First 20 by the permit is for one-hundred dollars ($100) or less.) ADDRESS, Additional I certify that in the,performance of the work for which this Total No. CITY !Tel No. � i Fixed Appliances Not Over 1 HP _ permit is issued, I shall not employ any person in any manner PERMIT p�*t 9�/ so'as to become subject to the Workers' Compensation Laws._ Range_Heater_D.W. 1 APPLICANT ,�`�`� GYI';�! �?L-�Y4 G� G�• a Oven Dryer W.M.— ADDRESS6 z Date Applicant Top _ FAU `W.H.._ CITY el.( 64 � Tel No �(PrI. Hood _ Fan _Other— NOTICE TO APPLICANT: If, after making this Certificate of ( Disp. — Room Air Cond. LICENSE OR *i � Exemption, you should :become subject to the Workers' REG.NUMBER1333ZClass Compensation provisions of the Labor Code, you, forth- i Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY with -comply with such provisions or`this permit shall be deemed revoked. Size&Type-HP,KW, KVA,or KVAR Up to 1-Incl_, - (� i JFINAL ' Over 1 to 10 Incl. DATE LICENSED CONTRACTORS DECLARATION, VALIDATION 50 Incl VALIDATION I hereby affirm that I am licensed under provisions of Chapter 'Over 50 to,,100 Inc. FINAL 9 (commencing.with Section 7000 of Division 3 of the Busi- i BY ( g. ) �' Over 100 ,ness and Professions.Code, and,my license is in full force and effect. Services" �33Sa e' 0-200 Amp. Under 600 V Lice NumbeF Lic.Class i fj t 201-1000 Amp. Under 600-V Contrac o a r `r 1 Over 1000 Amp.or Over 600 V y HOME OWNER-BUILDER DECLARATION Temp. Power Pole:&Appurtenances •I hereby affirm that `I am exempt( from the Contractor's Sign with One Branch Circuit - 0,0 O A .License Law for the.following reason (Section 7031.5, Busi- ness and Professions Code): _ ' #,0)o 10 0 0 2 Misc-.Conduits&Conductors D I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— '2 i-'o 8 2 3'6 ' structure is not, intended or offered for.sale (Section 7044,-Business and.Professions Code). ; :o,o 02 CONSTRUCTION LENDING AGENCY y 8 23 b I hereby affirm that there is a construction lending agency I for'the performance of the work for which this permit is �. O,5—8 issued (Sec. 3097,Civ.C.). ;PERMIT FEE (Sub-Total) Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 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 e above-mentioned prope ty for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE 1641 Signature of Permittee' Date WORKERS'COMPENSATIONDECLARATION CE-806 �PPUC/p� j`� N � I" �L� ��Ii�OICAL�, I!'LSRUVIIOII i - CE-806G (2-80) !i-� u L, Iry u u I hereby affirm that I have a'certificate of consent to self COUNTY OF LOS ANGELES t BUILDING AN SAFETY insure, or a certificate of Workers'Compensation Insurance,'or a ce tifi - cgpp the 6f(.1��c._4800,Lab.C.) �v (✓�'�,�% G�Q�� fJ FOR APPLICANT TO FILL IN JOB /6_- Policy o. __ Company / ADDRESS New Residential Bldgs.&Pools EACH NO. FEE Certified,copy is hereby furnished. $ — $ LOCALITY O Multi-family Sq. Ft. — NEAREST Certified copy is filed with the county building inspection CROSS ST Residential Swimming Pools department. . OWNER OR I l /� �d y,E` FIRM NAME v -`�. rTeoxgI,C Date 0 'QAtplicant Outlets: Re MAIL First 20 ` ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY ,I34elgi Tel Nn,_14 ,7. 1 COMPENSATION INSURANCE PLAN CHECK d (This,section. need •not be completed if the work involved APPLICANT O U Fixtures First 20 ADDRESS by the permit is .for one hundred dollars ($100) or less.) LigAdditional. Total No. I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. permit is issued, I shall not employ.any,person in any manner PERMIT W so as to become subject`to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT �/v���> `�� / 'ate CL Oven _ Dryer=W.M. ADDRESS Z Date Applicant Top _ FAU _W.H.._ n�^ pr Hood — Fan ._Other_ CITY ��� ,�sll ST el Nog 7 Q v NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond-_, LICENSE OR -yy Exemption, you should become subject to the Workers' REG. NUMBER -3,73-52-4!Iass Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT PROCESSED BY with comply with such provisions or this permit shall be Size&Type HP,'KW, KVA,or KVAR deemed revoked. Up•to 1 InclFINA Over 1 to 10 Incl. DAT L LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. — � VALIDATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 commencing with Section 7000 of Division 3 of the'. BY ( g ) Over 100 ness and Professions.Code, and my license is in-full force and VV effect. Services License Number&3-35-"Lic.Class / 0-200 Amp. Under 600 V Class. h 201-1000 Amp. Under 600 V r O� Contractor Date V / 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 Additional SignBranch Circuit Branch'Circuits • ' License Law for fhe following reason (Section 7031.5, Busi- ' • �0.0S O�9 A ness and Professions Code): Misc.Conduits&•Conductors #�010'0.6 0 2 I, 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). 7,V6 4 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency o 0.o 7 4,16 4 5 for the performance of the work for.which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,civ.C.). 0 15..0.5 8.1 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee). f 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 authorizereprese atives of this County to enter upon ` the rty for inspection purposes.urposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE GL,� pro Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76A663 n PP C n 7�� N ,FO EF1'2(r'TPUIC hid fi PEA J�,tl T / ' .,,CIE-806G (2-80) (i-11!'Ir L� G�1 Il ll�l IT Its 15L1-lS�b IIS G=�ll6 U'LS U�711 U 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,fnsurance,or. I I �7 -31 k a certified'.copy thereof(Sec. 3800,Lab.C.) \ 4 � <QO3'D(a�6' /7tE"i'v/Of�97 FOR APPLICANT TO FILL IN JOB a(� j�,� P,olily No. ompany / EACH; NO. FEE- ADDRESS v � 41C New Residential,Bldgs.&Pools �. Certified copy is hereby furnished; gt• �. $ — $ LOCALITY, � Z��� ��T Multi-family Sq. Ft. — L NEAREST - ❑ Certified copy is filed with the county building inspection CROSS ST department. i Residential Swimming Pools OWNER OR FIRM NAME Pate Applicant Outlets: Re MAIL - C'00S t�L 81V, ' i First 20, ADDRESS tir" CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY J � C=��,Tel No. 9 �, '��� } COMPENSATION INSURANCE PLAN;CHECK CL (This section need not be completed if the work involved APPLICANT O by the permit is.for-one hundred dollars ($100) of less.) Lighting Fixtures First 20 ADDRESS Additional Cr Total No. 0 I certify that in the performance of the work for which this Fixed Appliances Not Over,1.HP CITY Tel No: permit is issued, I shall not employ any person in any manner PERMIT �rG � � w. so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANTjv %���G.+�-• 0- Oven Oven _ Dryer_W.M. ADDRESS' r Top FAU —W.H. T'/2 ''�tT z. Date Applicant �? ''7 q��•— Hood — Fan. Other— CITY Tel No-/'� /'QC`fl j NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond— LICENSE OR Exemption, you'should' become* 33S z e 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, KVP,or KVAR deemed revoked. ev?—. Up to 1 Incl ` ' FINAL Over'1 to 10 Incl: DATE / LICENSED CONTRACTORS DECLARATIONOver 10 to 50 Incl VALJ DATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 inc. FINAL 9 (commencing with Section 7000 of Division 3 of the Busi- 6Y , ( S ) . Over 100 ness and Professions Code, and my license is in%full force and effect. Services 3 132.52 — j '? ' 0-200 Amp. Under 600 V' License Number tc.Class ' ©�_ ' 201-1000 Amp.Under 600.V , Contractor Date Over 1000 Amp.or Over 600,V HOME OWNER-BUILDER DECLARATION � Temp.Power Pole&Appurtenances Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's Additional Sign Branch Circuits License Law for the following reason (Section 7031.5, Busi- ness usi ness and Professions Code): ;2 0.0•Ca 7 A, 'Misc.Conduits&Conductors O I, as owner of the'property, will do the work and the Other (See Complete Fee,Schedule)- 00 0 0 02 structure is not intended or offered for sale (Section' 7044, Business and Professions Code). ' i CONSTRUCTION LENDING AGENCY o o _2.O'G 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). �o,olo,C�? 4 issued (Sec.'3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel O 0:5-,5 8 1 1 Lender's Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE D ' 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 t bove-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE. Signature of Permittee Date ) WORKERS'COMPENSATION DECLARATION 76A663 /1 fO�f"10 p C n 1' ION 2�1$) f�lj 2�5�1��� i1 fl ((� .Al�.�1145{' CE-806G (2-80) /�llr lr L� G,1 U 11V ,F Ili IEL E ll Ili AL- Yf� 11 11 I! 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 l\`_'/'/ � /_ / a certifi^ py t�r�f(S 3800,Lab.C.) � /S ` A'� � y �t FOR APPLICANT TO FILL IN JOB PoijNo. m/nY. � al(Bldgs. ADDRESS New Residenti &Pool EACH NO. FEE' Certified copy is he furnished. t, $ — $ LOCALITY 72;Jal,0e 4flTY, Multi-family Sq. Ft — r e NEAREST Certified copy is filed with the county.building inspection , CROSS ST depariment. Residential Swimming Pools OWNER OR �� �/ FIRM NAME Dater Applicant Outlets: R�k�F , MAIL r ADDRES ®d��. . k CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CIT 5,4/ jlC,-�L Tel N .:2 *Ze74 f } COMPENSATION INSURANCE PLAN CHECK _ CL APPLICANT O (This section need not be completed if the,work involved U by 'the permit is.for one hundred dollars ($100) or less.) Lighting Fixtures First 20, ADDRESS Additional cr Total No. 1 certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. � permit is issued, I shall not employ any person in any manner PERMIT U so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT 45r/V 70 ,0,,4 t-?�ec7R W.. CL Oven _ Dryer_W.M. ADDRESS6�`� ��y �� Date A licant Top FAY _W.H.. ( Q f PP CITY; 1 /4�r �Te1 No.�iQ� AHood — Fan _Other— . 7 ; NOTICE TO APPLICANT: If, after making this Certificate of I Disp. _ Room Air Cond.— LICENSE'OR g� r � _`� Exemption, you 'should become subject to the Workers' REG. NUMBER J �7 Class. Compensation provisions of the Labor Code, you must forth- 'power Apparatus& Large Appliances DISTRICT N 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. FINAL Over 1 to 10 Incl. DATE VALIDATION LICENSED CONTRACTORS DECLARATION 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 2 r License Number✓��� Lia Class Amp. Under 600 V i 0-200 C �f ry 201-1000 Amp. Under 600 V Contractor Date r7dP v 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 ❑ 1, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— :2 070 6 8 A structure is not intended or offered for sale '(Section 7044, Business and Professions Code). #1,0.0 0 oro 2 1 CONSTRUCTION•LENDING AGENCY I hereby affirm that there is a construction lending agency :2!00;0 9 8,6 4 w for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued(Sec. 3097,Civ.C.). ;o 0 0 9 g 8 4F . Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel ( 0'605=8� Lender's Address PERMIT ISSUING FEE - f 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 y ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon i the above.mentioned rropertt for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE 0.2 Signature of Permittee Date \