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HomeMy Public PortalAbout10679 FREER ST_Electrical__ WORKERS'COMPENSATIONDEGLARATION CE-806G 2-801 APPLICATION. FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELE BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or �V ! a certified copy thereof(Sec. 3800, Lab.C.) rJf / ^7 JOB Policy No. Company FOR APPLICANT TO EACH FILL N NO. FEE ADDRESS /D(7 / New Residential Bldgs.&Pools. Certified copy is hereby furnished, 1 &2-Family,Sq. Ft. $ _ $ LOCALI f ❑ Multi-family Sq. Ft. — NEARES Certified copy is filed with the county building inspection CROSS ST (,lJ department. Residential Swimming Pools OWNER OR FIRM NAME O Date Applicant Outlets. Rec.—Light Sw MAIL �)M� First 20 ADDRESS /7 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. _5-0-3 3g COMPENSATION INSURANCE } PLAN CHECK 0. (This section need not be completed if the work involved APPLICANT 0 Fixtures First 20 ADDRESS V by the permit is for one hundred dollars ($100) or less.) LigAdditional • Total No. tr I certify that in the performance of the work for which this CITY Tel No. 0- Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any manner PERMIT so as to become'subject to tJie-, orkersCo ensation Laws. Range_ Heater_D.W. APPLICANT ��/tf/� l7 �G( /� W Oven _ Dryer_W.M. CL ADDRESS o[ JJP�nry9��0� z 9.- Top _ FAU —W.H. �'t$ iS� O�aC Q Date Applicant � CITY Tel No. C^ Hood Fan _Other 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, T Class C_ Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances, DISTRICT NO. PRO,dE8 ED BY with comply, with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR deemed revoked. /�n t Up to 1 Incl. " Over 1 to 10 Incl. FINAL DATE LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. i��o VALIDATION I hereby affirm that I am licensed under provisions of Chapter Over 50,to 100 Inc. FINAL BY 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 l ness and Professions Code,and my license is in full force and effect. . Services - q-70p©3 0-200 Amp. Under 600 V License Number, Lic.Class (?/Jo �LQ�`?��/ � � 201-1000 Amp. Under 600 V �'- Contra ctor•C Nf" Date �' T �a Over 1000 Amp.or Over 600 V /���t�/� K HOME OWNE -BUILDER DECLARATION Temp. Power Pole&Appurtenances /!J I hereby affirm that I am exempt from the Contractor's Sign with-One Branch Circuit License Law for the following reason (Section 7031.5, Busi- ness and Professions Code). • Misc.Conduits&•Conductors 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). 221 '5;5A CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction-lending agency for. the performance of the work for which this permit is #'0'9'o, 'ofo 2 PERMIT FEE (Sub-Total) issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) •2,°;o 1 9'5 0 Lender's Address PERMIT ISSUING FEE o'o o 1 9.5 0 Z I certify that I have read this application and state that the TOTAL FEE 1C, ,0 9,,1.6 .. ,8,0' 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 P'4S,g e-mentio d�pertyfor inspection purposes. 4E-REVERSE FOR EXPLANATORY LANGUAGE / Date _ — \ I L7 '� WORKERS' COMPENSATION DECLARATION 10- APPLICATION FOR ELECTRICAL PERMIT I I rereby affitm that I. have-aCE-806G of consent to self CE-806G insure, ora certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec 3800, Lab C.) Policy No Company' FOR APPLICANT TO FILL IN JOB } Certified co is,hereb furnished EACH NO. FEE ADDRESS L / PY Y New Residential Bldgs &Pools ,�• , ❑ $ _ g LOCALITY:. Tf Certified copy is filed with the county building inspec- _ 1 8 2-Family, Sq. Ft. 1.� � L C.e 6h1, M 17 v tion department. Multi-family Sq Ft. — 'NEAREST CROSS ST Residential Swimming Pools OWNER OR Date Applicant FIRM NAME C5 C,V S–0 CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Lighti-Sw I& / MAIL " First 20 COMPENSATION INSURANCE b ADDRESS . C (This section need not be completed if the work involved by CITY Tel No. the permit is for one hundred dollars ($100)or less:) Total No Additional 5,I m e Y in e 1 certify that the of the work which this PLAN CHECK performance i APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Wo ers'•Compensation Laws Lighting Fixtures First 20 ADDRESS S Additional Date Applicant fs� Total No CITY Tel. No.- Fixed Appliances Not Over 1 HP PERMIT NOTIC TO APPLICANT• If, a m ing this Certificate of APPLICANT SJ9. Exem tion, you should bere subject to the Workers' Range_ Heater_D W — Compensation provisions of a 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 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 PR CES ED BY Power Apparatus 8 Large Appliances and Professions Code,and my license is in full force and effect. P d Size 8 Type HP, KW, KVA, or KVAR v O License Number Lic Class Up to 1 Incl. FINAL Over 1 to 10 Incl DATE f q,� OC Contractor Date U G VALIDATION 0 Over 10 to 50 Incl FINAL ~ I am exempt under Sec 7621 i P� Over 50 to 100 Inc. BY. B.BP C for this reason Over 100 Z Services, Swbd., MCC & Ponelboards ►� ; Date 0 - 200 Amp Under 600 V Signature 201 - 1 000'Amp Under 600 V ® Exemption for Reg Maint Elect. Over 1000 Amp or Over 600 V SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 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 Professions Code): ` 1, as owner of the property, will do the work and the Misc. Conduits 8 Conductors El structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 2 5 9 6,0,A 7044, Business and Professions Code) # 000002 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for o 0 2 Q 4I0 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec 3097, Civ. C ) - - o o o 2 Q.4 _ U PLAN CHECKING FEE " I 11„� 8 8 b Lender's Name PERMIT ISSUING FEE 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 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 nature 6f Permittee D to WORKER S',COMPENSATION DECIrARATION 76A663 .• CE-806G'(2--84) APPLICATION FOR ELECTRICAL PERMIT 1 hereby affirm that-I -have a certificate of consent ib 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.) FOR APPLICANT TO FILL IN JCB- Policy No. EACH NO. FEE ADDRESS Company 9 - New Residential Bldgs.&Pools • Certified copy is hereby furnished, 1 &2-Family,Sq. Ft. $ — $' LOCALITY Ft. NEAREST I ✓e Certified copy,is filed with the count building Multi-family wi mi CROSS ST y g inspection Residential Swimming Pools • department. OWNER OR •�-� FIRM NAMEhG�L^JS.� Date Applicant Outlets Rec11Light�Sv � AMA DDRESS /! �j!J/First 20 �� 7^ S CERTIFICATE OF EXEMPTION FROM WORKERS' Total No er� / Additional I•TY / I Tel No.�� (COMPENSATION INSURANCE PLAN'CHECK d APPLICANT O (This section need not be completed if the work involved Lam• V by the permit, is for one hundred dollars ($100) or less.) Lighting Fixtures First o ADDRESS S�}m ccf� Additional Total No., 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 W so as to become subject to the Workers' Compensation Laws. Range Heater_D.W. _ APPLICANT 0. ` Oven _ Dryer,4W.M. ` ADDRESS Z , Date Applicant Top _ FAU 1 W.H. _ — Hood Fan _Other_ CITY Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond._ /v LICENSE OR Exemption, you should become subject�to the Workers' REG. NUMBER Class Compensation provisions of the Labor Code, you must forth- Ppwer Apparatus& Large Appliances DISTRICT NO. PRO ESSED BY with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR deemed revoked. Up to 1 Incl FINAL /�'Q LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE r u U VALIDATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FIN / 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 Contractor Date Over 1000 Amp.or Over 600 V- HOME OWNER-BUILDER DECLARATION Temp. Power Pole.&Appurtenances < o,! 0,6'A I hereby affirm that I am exempt from the Contractor's Sign with One Brarich Circuit o'0 0 0 0 License Law for the following reason (Section, 7031.5, Busi- Additional Sign Branch Circuits 2 ness and Professions Code):' 2!0'- 57,00 Misc.Conduits&Conductors ® I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— { o to'o 'structure is not intended or offered for sale (Section ;, , 5 7' 0 G= C 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction iending'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 above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ^ ��Sign;%%rePermittee Date