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Home My Public Portal About9041 EMPEROR AVE_Electrical__ WOR KERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT CE-806 G (2-80) I hereby affirm that I have a certificate of consent to self 'COUNTY OF LOS ANGELEBUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or i a certified copy thereof(Sec. 3800, Lab. C.) FOR APPLICANT TO FILL IN JOB ��ryry Policy No. Company ADDRESS �G' E/d�P�� ' Ato New Residential Bldgs.&Pools EACH NO. FEE Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY 7Elm Y ❑ Multi-family Sq. Ft. — NEAREST ��- pG Certified copy is filed with the county building inspection CROSS ST G.J€/n�1�"� /J -VD department. Residential Swimming Pools OWNER OR � FIRM NAME ��GT• �Cv 11 Date Applicant Outlets: Rec.-.._Light Sw. MAIL C First 20 ADDRESS to ` 6• 1pE�tpRlt CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY 5,#t%J l;4,6,r?fC—[r Tel No.-2 } COMPENSATION INSURANCE PLAN CHECK a APPLICANT O (This section need not be completed if the work involved Lighting Fixtures First 20 ADDRESS U by the per is for one hundred dollars ($100) or less.) Additional cc Total No. 0 I certify that in the performance of the work for which thisF zed Appliances Not Over 1 HP CITY Tel No. permit is issued, I shall not employ any person in any manner PERMIT W W so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT d. Oven _ Dryer_W.M. ADDRESS Z z Date Applicant Top _ FAU _W.H.._ Hood — Fan _Other_ CITY o. 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 PR�SE 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 e —�� LICENSED CONTRACTORS DECLARATION � Over 10 to 50 Incl. VALIDATI 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- Over 100 BY ness and Professions.Code, and my license is in full force and _ effect. Servicesf �; d/ ,a, License Number Lic.Class 0-200 Amp. Under 600 V d 201-1000 Amp. Under 600 V 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 ness and Professions Code): Misc.Conduits&Conductors -941 0,3 A 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`o,o 0 0 2 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY .2'° ° 2 3.5 0 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 2 3.5 0,1=' issued (Sec. 3097,Civ.C.). Lender's Name -PLAN CHECKING FEE (One-Fourth Permit Feel 0 5.25-8.2. 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 T SignatqrCof•Pe mittee ate 76A663 10/81 WORKERS',COMPENATION DECLARATION APPLICATION FOR ELECTRICAL PERMIT firm tha't�ft have a.4ertKicate of consent, to self CE-806G in re, or a,certificafe 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 fin / (r• EM�EKG>�Certified copy copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE — SAi✓ ��$�iE� Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ $ LOCALITY Tion department. Multi-family Sq. Ft. — NEAREST �'VIA- CROSS ST. Date Applicant Residential Swimming Pools OWNER OR t�m& T .)C IIlp FIRM NAME /V VAP,it-" (C• CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec T( Light 2� Sw.�3 ''MAIL q COMPENSATION INSURANCE 90 ADDRESS rQ�/ E. eigpoeoe- �dE. s section neenot completed if the work involved b First 20 (Thitid t b p y Total No.� Additional CITY 441 A9iR)C.L_ Tel. No. Zs5-�/Eg 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 S/4/XE 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 Total No. Additional CITY Tel. No. Date Applica Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: aft��Certi icate of APPLICANT Exemption, you should b M e subject to the Workers' Range_ Heater_D.W. Compensation provisions of the Labor Code, you must forth- Oven J— Dryer W.M.— ADDRESS with comply with such provisions or this permit shall be Top —L FAU -W.H. — deemed revoked. HoodL Fan Other, CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. J- Room Air Cond. REG. NUMBER Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NC_ PROCESSED BY and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances ` l)� Size & Type HP, KW, KVA, or KVAR' (� License Number Lic. Class Up to 1 Incl. FINAL QP 09 Contractor Date Over 1 to 10 Incl. DATE V (DATION aOver 10 to 50 Incl. FINAL a I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 sn Services, Swbd., MCC & Ponelboards t Date: 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 ;2 6 8.1.0 A HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # 0 0 0 0,0 2 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 o - 91.50 Professions Code): ® I, as owner of the property, will do the work and the Misc. Conduits & Conductors o 0 o 9 1.5 0 U structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ polo Q, 0 6 i 8 7 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 `/1 I certify that I have read this application and state that the TOTAL FEE I V (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 the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE .- . Z::tzZ ;.26tZ- 9-817 ,'Signature Per ttee 1001 Date