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Home My Public Portal About4924 FIESTA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 10i81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES `j BUILDING AND SAFETY or as c�ti�fied copy thereof (Sec. 3800, JC.) PorZ`y" 'a S� d Pany FOR APPLICANT TO FILL IN JOB Q� • v Certified co is hereby furnished. EACH NO. FEE ADDRESS J PY Y New Residential Bldgs. & Pools S Ft. $ — $ LOCALITY T / .T 1 & 2-Famil El Certified copy is filed with the county building inspec- Y- q tion department. ., Multi-family Sq. Ft. — NEAREST Date S �=cS Z pplicant Residential Swimming Pools CROSS ST. d.]4 OWNER OR FIRM NAME N CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light�Sw.� MAIL COMPENSATION INSURANCE ADDRESS y /FrJ�iq V i' (This t bcompleted b First 20 ( s section neenoe com p if the work involved Y Total No. CITY .. Tel. No. the permit is for one hundred dollars ($100)or less.) Additional Erl 0 I certifythat in the performance of the work for which this PLAN HECK P APPLICANT permit is issued, I shall not employ any person in any manner so as to become subjectto the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT �C ��6C7' /4 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. Na,9,&7-/,1Z36 LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESS D BY and Professions Code, and my license is in full force and effect. Power Apparatus & Large Appliances ,/- Size&Type HP, KW, KVA, or KVAR' J s®� License Number 4/2-5-2 32— Lic. Class L(L Up to 1 Incl. FINAL k) /1U�f_ ` �.a�- $3 Over 1 to 10 Incl. DATE 5_ _�� , VALIDATION Contractor/� /CS .rtN�ate Over 10 to 50 Incl. cJ F a a FINAL � I am exempt under Sec. Over 50 to 100 Inc. BY 8.&P.C. for this reason Over 100 Services, Swbd., MCC & Panelboards pop. ��`� . 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 2 3 2 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 2 -.- 30.5.0 Professions Code): = I, as owner of the property, will do the work and the Misc. Conduits& Conductors o,o 0 3 0,5 Q� structure is not intended or offered for sale (Section Other.(See Complete Fee Schedule)- 001 7044, Business and Professions Code). 0 5 2 5- 3 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) Zia (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE CU 5 Lender's Address o !� I certify that I have read this application and state that the TOTAL FEE , J 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 propeLLY fo nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm+that I have a certificate of consent to self CE-806G insure, or a certificate of'Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY Dull or a certified copy thereof (Sec. 3800, Lae. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS 2� Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE S — Certified copy is filed with the county building inspec- 1 & 2-Family, q� Ft. $ $ LOCALITY j tion department. Multi-family Sq. Ft. NEARESTCROSS ST. Residential Swimming Pools OWNER OR ► q d a! Date Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec L!!�Light_]�LSvv. ' r MAIL n COMPENSATION INSURANCE _ ADDRESS �` st 20 (This section need not be completed if the work involved by Total NoFir Additional CITY �� C`I Tel. No the permit is for one hundred dollars ($100)or less.) performance of the work for which this PLAN CHECK I certify1 , , that in the P APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures 15 First 20 ADDRESS 4 'CS A "if1c4.te .0 Total No. Additional _Date i A Iica CITY E l� ( Tel. No2� �PP ixed Appliances Not Over 1 HP PERMITNOTICE TO A P (CANT: If, of er making t iAPPLICANT 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 Disp. Room Air Cond. LICENSE Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. P CES ED BY Off. and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances p 0 Size &Type HP, KW, KVA, or KVAR eq V License Number Lic. Class Up to 1 Incl. FINAL 0: Over 1 to 10 Incl. DATE �� VALIDATION Contractor Date Over 10 to 50 Incl. FINAL El W I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 Date: Services, Swbd., MCC & Panelboards 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V aExemption 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 1 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 �essions Code): I, as owner of the property, will do the work and the Misc. Conduits& Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 5 9 3,6 A 7044, Business and Professions Code). # o o o o 0 2 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for I o o 4 2 2 5 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). 0 -,o 4 2 2 5 5 PLAN CHECKING FEE Lender's Name 1, 4.�8 6 PERMIT ISSUING FEE Q Lender's Address I certify that I have read this application and state that the TOTAL FEE ?j 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 p 0-PI/1- Signature of PSignature of P itteee Date