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Home My Public Portal About5215 FARAGO AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76-663 . 10/81 APPLICATION FOR ELECTRICAL PERMIT 1 hereby affirm that I have a certificate of consent to self insure, SCE-8osGF L, I or a certificate of Workers' Comp(%sation IrlSurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY U copy thereof(Sec. 3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB rJ( ❑ Certified copy is hereby furnished. New Residential Bldgs. & Pools L EACH NO. FEE ADDRESS ❑ Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft.--a� $ — $ LOCALITY department. Multi-family Sq.Ft. — NEAREST CROSS ST. Date Applicant Residential Swimming Pools OWNER ORp FIRM NAME en� /v[�✓'^%o CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light Sw. MAIL `I ^� COMPENSATION INSURANCE ADDRESS :S h (iLJ o (This section need not be completed if the work involved by the First 20 Total No. Additional CITY Tel.°No. permit is for one hundred dollars ($100) or less.) -J 13� 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 ' !' Total No. Additional Date J Applicant w��"[ �r'�`�"` CITY Tel.No. Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after makingPERMITS ' phis Certificate 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 aae !a 1— provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _ CITYTel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ '��I'�•---'•' I hereby affirm that I am licensed under provisions of Chapter 9 Dis — Room Air Cond. LICENSE OR 71 (commencing with Section 7000) of Division 3 of the Business and p REG.NUMBER .7�� Class. —/&,> Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSED BY Power Apparatus& Large Appliances ?:. �;_ Size& Type HP,KW,KVA,or KVAR ` C� License Number J Lic.ClassUp to 1 Incl. FINAL V Over 1 to 10 Incl. DATE VALIDATION Contractor �' Date Over 10 to 50 Incl. I— ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C.for this.reason Over 100 [/ CO ix, Services, Swbd.,MCC& Panelboards I 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 L HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCTA I 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 3307115.20 Code): i 1 T ❑ I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors 1TEMS is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ TOTAL 115. 20 and Professions Code). ► CHECK 115°20 CONSTRUCTION LENDING AGENCY CHANGE °[► i I hereby affirm that there is a construction lending agency for the flet performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ.C.). PLAN CHECKING FEE 4/25/90 Lender's Name 0300 1 AM 7:49 PERMIT ISSUING FEE � utr Lender's Address I certify that I have read this application and state that the above TOTAL FEE inform n is correct. I agree to comply with all County ordinances and t e laws regulating Electrical wiring, and hereby authorize repretatives of this County to enter upon,the above-mentioned propel' for inspect' purpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE ure f Permittee Date WORKERS'COMPENSATION DECLARATION 76A66eaPwsiaz APPLICATION FOR ELECTRICAL PERMIT I he ebyVaffirm that I have a certificate of consent to self cE e06c i`3ure,`''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 FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS Certified copy is filed with the county building inspec- 1 & 2-Family;-Sq. Ft. LOCALITY$ — $ 6t tion department. Multi-family Sq. Ft. — NEARESTCROSS SY2Q� Residential Swimming Pools OWNER OR Date Applicantn ,7/ �/ FIRM NAME Y,�c CL/.�L��`/ eQr"--�'' 17AA CERTIFICATE OF.EXEMPTION FROM WORKERS' ' Outlets: Rec Light Sw.— AMAILDDRESS ` I 1 JI— COMPENSATION Gr(x(14 COMPENSATION INSURANCE First 20. c� (This section need not be completed if the work involved by Total No. Additional CITY �I Tel. No.cq'(p Sow- !x q , 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 permit is issued, I shall not employ ony.person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this 'Certificate of APPLICATION z7 1 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 beTop FAU —W.H. — deemed revoked. CITY Tel. No. Hood — Fan —Other— LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. REG. NUMBER Class. I hereby affirm that I am licensed under provisions of Chapter (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. P OC SE BY a and Professions Code,and my license is in full force and effect. Size &.Type HP, KW, KVA, or KVAR O License Number Lic. Class Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE VALIDATION 0 Contractor Date Over 10 to 50 Incl. QFINAL V I am exempt under Sec. Over 50 to 100 Inc. BY LLl B.&P.C. for this reason Over 100 01 Services, Swbd., MCC & Panelboards , Z Z Date: 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V D Exemption for Reg. MainOver 1000 Amp. or Over 600 V L Elect. SINGLE FAMILY [T:em�p. PowerPole &Appurtenances _HOME OWNER-BUILDER DECLARATIONa I hereby affirm that I am exempt from the Contractor's Licenseigf�l•t•I=s � Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 3117 �;�,;.00 LL Profssions Code): i .(TEM I, as owner of the property, will do the work and the Misc. Conduits&Conductors �� truiness and Professions Code)cture is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , TOTAL ,=p,:t Bus . 3�e CHECK Llt� CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CHANGE the performance of the work for which this permit is'issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE 01 lIO-0001 Lender's Name PERMIT ISSUING FEE 26 1 AM 9 [I Lender's Address 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 Stat aws regulating Electrical wiring, and hereby authorizer r sentatives of this County to enter upon t above-mentio e property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of PeYriiittee Date I WORKERS'COMPENSATION DECLARATION -663 10/81 CE-806G APPLICATION FOR ELECTRICAL PERMIT J� CE-806GI hereby affirm that'I have a certificate of consent,to self insure, -• or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab..C.). jPolicy No. Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ❑ 1 & 2-Family,S Ft.--620 $ — $ LOCALITY Certified copy is filed with the county building inspection y� q� department. Multi-family Sq.Ft. — NEAREST CROSS ST. DateApplicant Residential Swimming Pools OWNER OR , FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light _ Sw. MAIL /s- � b�`F/ COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the CITY � Tel. No. permit is for one hundred dollars ($100)or less.) Total No. First 20 Additional C��;z 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 Additional %} t ' Total No. CITY Tel.No. Date Applicant 4� NOTICE. TO APPLICANT:, If, after making this Certificate Fixed Appliances Not Over 1 HPicate of PERMIT //�� Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT /r/<G. 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. _ CITYTel:No. a r ¢ LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ lel �� 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 Disp. — Room Air Cond. REG.NUMBER —IT 77::� Class:fQ Professions Code,and my license is in full force and effect. DISTRICT NO.,,. j�� PRo SED BY Power Apparatus& Large Appliances f'{l/ �1 /U Size& Type HP,KW,KVA,or KVARi License Number �/J /�J� Lia.Class C Up to 1 Incl. FINAL U Over 1 to 10 Incl. Contractor /��7it 1 �'L'+i� Date__ FU DATE VALIDATION O ❑ Over 117— 0 to 50 Incl. FINAL V I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 Date: pfv Services, Swbd.,MCC & Panelboards ® Z 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 2 I 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 ,�rl+�0 4 u Code): 3307 ❑ Misc.Conduits & Conductors t9►r4 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 Fee Schedule) _ 1 ITE and Professions Code). , TOTAL - 1 .¢3 • {'.!1 P4� �1..EL5 o .c�'.0 CONSTRUCTION LENDING AGENCYCHECK r, 11Ju� I hereby affirm that there is a construction lending agency for the d performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ.C.). t:H0M .011 PLAN CHECKING FEE a Lender's Name PERMIT ISSUING FEE 3 10-0001 4/25/90 Lender's Address p t -f I certify that I have read this application and state that the above TOTAL FEE I 0302 1 AM 7044' information is correct. I agree to comply with all County ordinances andSt e laws regulating Electrical wiring, and hereby authorize ' rep to fives of this County to enter upon the above-mentioned propert f r inspection urpose SEE REVERSE FOR EXPLANATORY.LANGUAGE Si of rmittee Date