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HomeMy Public PortalAbout5472 ENCINITA AVE_Electrical__ WORKERS' COMPENSATION DECLARATION zo-oolvDPW 3ie7 APPLICATION FOR ELECTRICAL PERMIT O I ,herebCE_806 y affirm that I have a certificate of consent to self CE-806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company �S FOR APPLICANT TO FILL IN. JOB eltertified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ElCertified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY tion dep rtment. Multi-family Sq. Ft. NEAREST Residential Swimming Pools CROSSOWNERS T. Date Applican,� O FIRM NAMR E CE IFICATE OF EXEMPTION F W RKE Outlets: Rec Light Sw.— MAIL �• /s� -� COMPENSATION INSURANCE First 20 ADDRESS (This section need not be completed if the work involved by Total No. Additional CIT v Tel. No.o�E239 the permit is for one hundred dollars ($100)or less.) PLAN CHEC � / I certify that in the performance of the work for which this APPLICANT � G�E Plllj G //p 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 141 L7,5- Additional Total No. CITY °�/LC � Tel. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION 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 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 �Sj �/ Disp. — Room Air Cond. 6/ Class. REG � I hereby affirm that I am licensed under provisions of Chapter 9 . NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY 0..} and Professions Code,and my license is in full force and effect. D Size &Type HP, KW, KVA, or KVAR 0 License Number Lic. Class Up to 1 Incl. FINAL U Over 1 to 10 incl. DATE ZZ e46 VALIDATION 0 Contractor Date Over 10 to 50 Incl. 0 ElF I am exempt under Sec. Over 50 to 100 Inc. 0 U W Over 100 d B.&P.C. for this reason Services, Swbd., MCC & Panelboards U) Date: Z 0- 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V z 9 8 I.8 A ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V # o o o o o 2 SINGLE FAMILY I o - 2S50 Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION I-hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit = Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits o -,o 2 S 5 O Professions Code): 0 61 5-88 ❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ 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 TOTAL FEE -01� I certify that I have read this application and state that the i 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 Wit' ©s Signatu of Pe tt Dc4 JRKERS' COMPENSATION DECLARATION CE-806G 10/87 APPLICATION FOR ELECTRICAL PERMIT nrm 'het I have a certificate of consent to self insure, -! ! Idle of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY areof (Sec. 3800.Lab. C.) cy No. Company FOR APPLICANT TO FILL IN JOB { {- Certified copy is hereby furnished. New Residential Bldgs. &sP-ools EACH NO. FEE ADDRESS 5r-7 Z-- �.LIj,L((,� Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. Cr3U0 $ — $ v LOCALITY ' department. Multi-family Sq.Ft. — NEAREST CROSS ST e Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL COMPENSATION INSURANCE ADDRESS rc� is section need not be completed if the work involved by the First 20 mit is for one hundred dollars ($100) or less.) Total No. Additional CITY JG�✓ 641tPLAN CHEC Tel.Nq,2 ,; > rtify that in the performance of the work for which this permit APPLICANT K ;sued, I shall not employ any person in any manner so as to ome subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS � _lC G Total No. Additional CITY Tel. No I Applicant �l�Y�C �+WyCC Fixed Appliances Not Over 1 HP 'ICE TO APPLICANT: If, after making this Certificate of PERMIT APPLICANT nption,you should become subject to the Workers'Compensation Range_ Heater_ DW isions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. _ ADDRESS `tel . J isions or this permit shall be deemed revoked. Top _ FAU _ WH _ CITY r - �- LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ yui Tel.No.h25 eby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG NUMBER Class _fro mencing with Section 7000) of Division 3 of the Business and REG NUMBER scions Code,and my license is in full force and effect. Power A DISTRICT NO. PROGESSE•D BY Apparatus& Large Appliances ^f _ �t 3 n Size & Type HP,KW,KVA,or KVAR �' �- 1- IL se Number�l 5 /i Lic.Class Up to 1 Incl. FINAL U _ Over 1 to 10 Incl. DATE actor � Y�C� Date 5-3� VALIDATION O Over 10 to 50 Incl. FINAL ' 0 I am exempt under Sec. Over 50 to 100 Inc. gY U _ W B.&P.C. for this reason Over 100 Cl) Services, Swbd.,MCC & Panelboards Z 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 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit y affirm that I am exempt from the Contractor's License Law following reason (Section 703 1.5, Business and Professions Additional Sign Branch Circuits Misc.Conduits& Conductors as owner of the property,will do the work and the structure s not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) Ind Professions Code). CONSTRUCTION LENDING AGENCY affirm that there is a construction lending agency for the ance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) PLAN CHECKING FEE I Name PERMIT ISSUING FEE l� Address that I have read this application and state that the above TOTAL FEE 7 j on is correct. I agree to comply with all County ordinances Is laws regulating Electrical wiring, and hereby authorize tatives of this County to enter upon the above-mentioned for inspect' n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE of Ilermittee Date