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HomeMy Public PortalAbout9160 EMPEROR AVE_Electrical__ WORKERS'COMP1 JSATI6N DCLARATIOiV 63 APPLICATION FOR ELECTRICAL PERMIT •` CE 8 CE 806E(2 80) � I frereby affirm that I have a certificate of consent to self l 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 Policy No Company EACH NO FEE ADDRESS New Residential Bldgs &Pools Certified copy is hereby furnished 1i&2-Family,Sq Ft 1 $ — $ LOCALITY T.DV Multi-family Sq Ft — NEAREST Certified copy is filed with the county budding inspection Residential Swimming Pools CROSS ST department �' OWNER OR • FIRM NAME Date Applicant Outlets Rec—Light_ Sw MAIL First 20 ADDRESS -f— CERTIFICATE f ,CERTIFICATE OF EXEMPTION FROM WORKERS' Total No 'Additional CITYkr el No 443 COMPENSATION INSURANCE ' 6 } PLAN CHECK I tl APPLICANT O• (This section need not be completed if the work involved U by the permit is for one hundred dTotal No Additional($100) or less) Lighting Fixtures First ADDRESS onal cc I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No U 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 d Oven _ Dryer_W M ADDRESS Z Top _ FAU _W H Z Date Applicant _ Hood _ Fan _Other_ CITY Tel No , NOTICE TO APPLICANT If, after making this Certificate of Disp _ Room Air Cond_ LICENSEIOR 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 PROCESWb BY with comply with such provisions or this permit shall be deemed revoked Size&Type HP, KW, KVA,or KVAR Up to 1 Incl FINAL Over 1 to 10 Incl GATE LICENSED CONTRACTORS DECLARATION VALIDATION 1 Over 10 to 50 Incl t� G 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 Services License Number Lic Class 0-200 Amp Under 600 V 201-1000 Amp Under 600 V ;90 7 3.5 A Contractor Date Over 1000 Amp or Over 600 V HOME OWNER-BUILDER DECLARATION .14 Ind # o`0 0 0 0 2 Temp Power Pole&Appurtenances _ Sign with One Branch Circuit 2 ° ° 1 7 0 0 I hereby affirm that I am exempt from the Contractor's Additional Sign Branch Circuits Licens aw for the following reason (Section 7031 5, Busi- o'0 0 1 7,000' ness d Professions Code) Misc Conduits&Conductors 0 8 1 2-81 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) 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 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 bo a-me oned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE -Signature of Pe mute Dft e l i • WORKER S'COMPENSATION DECLARATION CE806G (280) APPLICATION FOR ELECTRICAL PERMIT 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) //� /T JOB Policy No Company FOR APPLICANT TO EACH FILL N NO FEE ADDRESS bD ERCA New Residential Bldgs &Pools i Certified copy is hereby furnished 1 &2-Family,Sq Ft a� $ — $ LOCALITY v Multi-family Sq Ft — NEAREST Certified copy is filed with the county building inspection CROSS ST � department Residential Swimming Pools OWNER OR FIRM NAME V�1^✓ Date Applicant Outlets Recr�Lignj Sw MAIL First 2 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITYTel No —sl� �- } COMPENSATION INSURANCE PLAN CHECK a APPLICANT O (This section need not be completed if the work involved U tio Addional by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First ADDRESS cc Total No 0 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 lJJ so as to become subject to the Workers' Compensation Laws Rapge_ Heater D W APPLICANT p_ Oven ,Dryer W M _ ADDRESS N Date Applicant Top FAU' W H Z Hood Fan Other_ CITY T 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 PRQCES2ED BY with comply with such provisions or this permit-shall be Size&Type HP, KW, KVA,or KVAR deemed revoked l©� Up to 1 Incl a FINAL Over 1 to 10 Incl DATE Q' LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl U 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- Over 100 BY ness and Professions Code, and my license is in full force and f effect Service License Number Lic Class 0-200` p Under 600 V 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 1 6 1,8 A Licens Law for the following reason (Section 7031 5, Busi- Additional Sign Branch Circuits Foy # 002 ness d Professions Code) Misc Conduits& Conductors 2 0 - 82 0 0 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 8 2 0 0 v 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm tha—t there is a construction lending agency 1 n,20—8 1 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 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- entioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE &.1)?n,0....-A Signature of rmi tee Date