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HomeMy Public PortalAbout5101 - 5107 FARAGO AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-663 10/61 APPLICATION FOR ELECTRICAL PERMIT �1 I her@by:af;irm th t-* have a ce!tificate of consent to self insure, CE-806G or a cerlrtf,ate of yvorkers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy th&eof(Sec.3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ^� _ ❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS 17 r �.�b 3 (� A- New Residential Bldgs.& Pools ❑ Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. T $ — $^ LOCALITY department. Multi-family Sq.Ft. J2 — NEAREST Date Applicant Residential Swimming Pools CROSS ST. A(` , OR FOIRM WNER NAME ��/V /V r e- CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light _ Sw. — MAIL COMPENSATION INSURANCE .ADDRES (This section need not be completed if the work involved by the First 20 permit is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.No. I certify that in the performance of the work for which this permit PLAN CHECK is issued, I shall not employ any person in any manner so as to APPLICANT become subject to the Workers'Compensati Law Lighting Fixtures First 20 ADDRESS `� Total No. Additional I2 _17`A CITY Tel.No. Date pplicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after <ing this Certificate of PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT L provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _ CITY LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ Tel.No.C C� 7� �� I hereby-affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class. , ,f (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. .DISTRICT NOPRO BY Power Apparatus&Large Appliances Size& Type HP,KW,KVA,or KVAR `6/� O License Number 3 t a �- ` Lia Class Up to 1 Incl. FINAL /J U Contractor ( �2� �DC�1`C<hDate /A-A �� Over 1 to 101nc1. DATE [/ �/ ✓ VALIDATION Q Over 10 to 50 Incl. FIN I_ I am exempt under Sec. Over 50 to 100 Inc. g W B.&P.C.for this reason Over 100 N Services,Swbd.,MCC& Panelboards e r ^ate:,t 0-200 Amp.Under 600 V Signature -- y v 201 - 1000 Amp.Under 600 V ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V SINGLE FAMILY Temp.Power Pole& Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits for the following reason (Section 7031.5,Business and Professions Code): ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 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(Sec.3097, PERMIT FEE (Sub-Total) p Civ.C.). # ��� ��� PLAN CHECKING FEE Lender's Name 1 -1 3 Q 5 0 PERMIT ISSUING FEE Lender's Address ° ° 1 3 Q 5 0'5 I certify that 1 have read this application and state that the above TOTAL FEE229-87 information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize repr entatives of this County to enter upon the above-mentioned p!9t for in ection pur s q �y SEE REVERSE FOR EXPLANATORY LANGUAGE it Signature of Permittee V Date" WORKERS' ave a cJSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT �y CE-806G 4,hereb� �'f4^,:tt��have a certificate of consent to self insure, �$r a cercate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec'3800,Lab.C.) Policy No. - Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS New Residential Bldgs.& Pools ❑ 1 & 2-Family,Sq.Ft. $ — $ LOCALITY / G Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. — NEAREST �iesf Y_ CROSS ST. Residential Swimming Pools OWNER OR Date Applicant FIRM NAME Qi + CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light Sw. MAIL COMPENSATION INSURANCE ADDRESS i 1 9- (This section need not be completed if the work involved by the First 20 D �• permit is for one hundred dollars ($100)or less.) Total No. Additional CITYL-1 JCL Tel.No. j2 I certify that in the performance of the work for which this permit PLAN CHECK is issued, I shall not employ any person in any manner so as to APPLICANT become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS 11 ,�� Additional H I GS, Total No. CITY Tel.No. Date 1- 7 Applicant t Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: -If, after making this Certificate PERMIT of Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top FAU W.H. LICENSED CONTRACTORS DECLARATION CITY Tel.No. Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class. (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO PROC SED BY ' Size& Type HP,KW, KVA,or KVAR License Number Lic.Class Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE Contractor Date VALIDATION O ❑ Over 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. BY W BAP.C. for this reason Over 100 -7 Z G. N Services,Swbd.,MCC&Panelboards oil.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. �797,.1 A SINGLE FAMILY Temp.Power Pole& Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # 0 0 0 0 0 2 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits I 0 0 2 5 5 O Code): Misc.Conduits& Conductors - 25505 1,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , Q 9.2 2 b 8 7 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(Sec.3097, PERMIT FEE (Sub-Total) 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 above TOTAL FEE Sr information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize re r ntatives of this County to enter upon the above-mentioned pr rt for ins p ction pur o s. G SEE REVERSE FOR EXPLANATORY LANGUAGE — Si a ure of Permittee Date i WO�tKERS'COMPENSATION DECLARATION 76-663 ,ops,FPV " APPLICATION FOR ELECTRICAL PERMIT I he•eby �ffirrn that.d Have a. certificate of consent to self insure, CE-806G . •-erre GeR+Yticate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thgreof(Se2-.'3800.Lab.C.) rl Policy No. Company FOR APPLICANT TO FILL IN JOB ❑. Certified copy is herebyfurnished. EACH NO. FEEADDRESS New Residential Bldgs.& Pools ❑ 1 & 2-Family,Sq.Ft. =�.p� $ _ $ LOCALITY Certified copy is filed with the county building inspection , �'� NEAREST department. Multi-family Sq.Ft. � CROSS ST. Date Applicant Residential Swimming Pools OWNMER ORd+V FIRNAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec&Light,'V_U SW.. MAIL ADDRESS © AA/CL COMPENSATION INSURANCE This section need not be completed if the work involved by the First 2 ( P CITY Tel.No. permit is for one hundred dollars($100)or less.) Total No. Addi' nal A PLAN CHECK I certify that in the performance of the Work for which this permit APPLICANT is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compe ion aws. Lighting Fixtures First 20 ADDRESS Additional � ��—X7Applicant Total No. CITY Tel.No. Date Fixed Appliances t O r 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certi ate of Exemption,you should become subject to the Workers'Compensation Range_ eater D.W.� APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven Dryer W.M. ADDRESS t provisions or this permit shall be deemed revoked. Top FAU H. CITY Tel.No. ' 2 LICENSED CONTRACTORS DECLARATION Hood Fan O er_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR (commencing with Section 7000) of Division 3 of the Business and Dis Room Air Cond. REG.NUMBER Class. -2 Q Professions Code,and my license is in full force and effect. Powe Apparatus& Large Applian es DISTRICT NO. P S D BY 00-1 p n' Size&Type HP,KW,KVA,or KVAR 5 .- VO License Number �D i� Lia Class ` Up to 1 Incl. FINAL oe Over 1 to 10 Incl. DAT B VALIDATION Contractor kM9R(C. Date Over 10 to 50 Incl. O jP��j� F V I am exempt under Sec. Over 50 to 100 Inc. IL g ta,! B.&P.C.for this reason Over 100 Services,Swbd.,MCC&Panelboards N Da 0- 200 Amp.Under 600 V 4k I Signature 201 - 1000 Amp.Under 600 V FI Exemption 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 I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits Code): ❑ Misc.Conduits & Conductors I,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business Other(See Complete Fde Schedule) and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the 8 b 7,4 A performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) # 0 0 0 0 0 2 Civ.C.). PLAN CHECKING FEE I o 1 3 Q 5 0 Lender's Name PERMIT ISSUING FEE Q 5D o 0 13 0 5 0 C5 Lender's Address I certify that I have read this application and state that the above TOTAL FEE O 229-87 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 pLege ty for inspection p poses. (// ose — > SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permitte/ bl Crate --�