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Home My Public Portal About4515 ELLIS LN_Electrical__ WORKERS'COMPENSATION DECLARATION A CEU=PPL�ICAUUON FOR ELECTRICAL P[SRI/Y%U� ll • CE-880606 G (2-80) 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'sSec. 3800 Lab.C.) C(5-05770-(•3'1 /,� en''__ ,Q A FOR APPLICANT TO FILL IN JOB c� r f, Policy No. Company I� ""� Mg, 19MEI 104 EACH NO. FEE ADDRESS 6_® `• �� L��L1E New.Residential Bldgs.&Pools Certified copy is herebyfurnished. 1 &2-Family;Sq. Ft. $ — $ LOCALITY Multi-family Sq. Ft. — NEAREST LCertified copy is filed with the county building inspection' CROSS ST h department. n Residential Swimming Pools OWNER OR t 1�19 /(jJ FIRMNAME1=1a1ZiL>` Date Applicant ' Outlets: Rec._Light .Sw. - MAIL n First 20 ADDRESS (0Q s� �Ag�I CC CERTIFICATE OF EXEMPTION FROM WORKERS' Tota I.No. Additional CITY S COMPENSATION INSURANCE PLAN CHECK C Tel No. Z�7— ]ZI a K • 0 APPLICANT (This section need not be completed if the 'work involved U -Fixtures First 20 Lighting ADDRESS by the permit is for one hundred dollars ($100) or less.) LigCr Additional I certify that in the performance of the work for which this Total No. CITY Tel No. Fixed Appliances Not Over 1 HP U permit is issued, I shall not employ any person.in any manner PERMITS�T�tc AS $o�It LU so, as to become subject to the Workers'. Compensation Laws. Range_ Heater_D.W. APPLICANT' d Oven Dryer_W.M. ADDRESS z Date Applicant Top _ FAU _W.H. 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 Co' pensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE SED BY wi cem ply with such provisions 'or this permit shall be deemed-revoked. Size&Type HP,KW, KVA,or KVAR �, �/ Up to 1 Incl. FINAL v Over 1 to 10 Incl. LICENSED CONTRACTORS DECLARATION DATE �— � VALIDATION Over 10.to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc.*, BY AL t 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 15L Lic.Class 6Q 0-200 Amp. Under 600 V 201-1000 Amp. Under 600 V 'Contractor.I. R tG� Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances O Sign with One Branch Circuit x;3,7 a 9 A I hereby affirm that I am exempt from the Contractor's Additional Sign.Branch Circuits # o'.0 0 0 0 2 License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): Misc.Conduits&,Conductors 2.0.0 1 7,00-- EJ 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 •o 0 0 17 0 0 7044, Business and Professions Code). " CONSTRUCTION LENDING AGENCY 0 1..1 9-81 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 (Seca 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE 7 I certify that I have read this application and state that-the TOTAL FEE , (7 above information is correct.I agree to comply with all County ordinances and State laws regulating Electrical wiring, and I 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 'WORKERS'COMPENSATION DECLARATION 76A663 10/81 n (p7�� n�O��n �O� IC�j� �� /� Q MEMO Whereby*iffirm That I have a certificate of consent to self CE-806G /i=�U� (�1 l]V E E l�[j�Ll ��CWp�Jp p insure, ora certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING ARID SAFETY or a e fied cop tth�er�eof Sec 3800, Lab. C.) •"" � FOR APPLICANT TO FILL IN JOB Polio. Company ADDRESS Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE 1 8 2-Family, S Ft. $ — $ LOCALITY 77 Certified copy is filed with the county building inspec- Y. q. tion department. Multi-family Sq. Ft. — 'NEAREST Residential Swimming Pools CROSS ST. Date 2:11 A 31 -Appli ant AA OWNER OR FIRM NAME �– CERTIFICATE OF EXEMPTION FROM WORKERS' Outl , MAIL ets: Rec Light Sw._ ADDRESS COMPENSATION INSURANCE First 20 (This section need not be completed if the work involved by Total No. CITY Tel. No. the permit is For one hundred dollars ($100)or less.) Additional that in the performance of the work for which this PLAN CHECK I certify P APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS TAdditional Total No. CITY Tel. No. Date Applicant 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 O )a G L "M oo with comply with such provisions or this permit shall be Top_. — FAU —W.H. — deemed revoked. Hood Fan _Other_ CITY -Am sk, C�� Tel; No. '7 111 LICENSED CONTRACTORS DECLARATION 'LICENSE OR Disp. — Room Air Cond. REG. NUMBER Class. I hereby affirm that I am licensed under provisions of Chapter 9 �' (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROC�S ED BY and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances 6- j - 0- Size & Type HP, KW, KVA, or KVAR' QQ O License Number 4/-S25 _7Lic. Class �_ Up to 1 Incl. i• d FINAL ® / Over 1 to 10 Incl. DATE i s 0 Contractor a Date r' LIDATIOW O ❑ Over 10 to 50 Incl. E1NAL ~ V I am exempt under Sec. Over 50 to 100 Inc. (8y LU B:&P.C. for this,reason Over 100 r Date: Services, Swbd., MCC & Panelboards !! 0 -200 Amp. Under 600 V ;0 1 6.8, 1 A Signature 201 - 1000 Amp. Under 600 V 'o o'T 5' F] Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. 00 0 1 525=0 SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION 02 1 3-8 5 Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and Professions Code): 1 El1, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— D 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 Lender's Address ' I certify that I have read this application and state that the TOTAL FEE !J 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 ab ve ioned property for inspection purposes. SEE REVERSE.FOR EXPLANATORY LANGUAGE azure' f Pe mittee Date