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Home My Public Portal About5525 GOLDEN WEST AVE_Electrical__ � °firrn VIERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION .FOR ELECTRICAL PERMIT I,hereby affi�m tSiat I have a certificate of consent to self insure, CE-Bose or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab. C.) _ ''FOR APPLICANT TO FILL IN JOB ' Policy No. Company ADDRESS 57d e K tiV� 5 Certifiedct ay is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ' 1 & 2-Family, Sq.Ft. $ — $ LOCALITY -7-G�r /e Certified copy is filed with the county building inspection — 6114-1 department. Multi-family Sq.Ft. NEARESTCROSS ST Date Applicant Residential Swimming Pools:; ,° OWNER OR FIRM NAME d.T ow Yee- / CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light — S' — 'MAIL COMPENSATION INSURANCE W. ADDRESS iL C> Yi --e rr0 t5 (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 �� TelNo.2l 3 _6IF/T .1-Y I certify that in the performance of the work for which this permit PLAN CHECK APPLICANT 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 Additional Total No. CITY Tel.N . Date 2-�- 90 Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If; after making this 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 provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ LICENSED CONTRACTORS DECLARATIONCITY Tel.No. Hood — Fan Other_ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Class. Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. ` PROCE SED B " Size& Type HP,KW,KVA,or KVAR ( /1) O License Number Lic.Class Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE ALIDATION Contractor Date J Over 10 to 50 Incl. V FINAL I am exempt under Sec. 70 e Z,y Over 50 to 100,Inc. FBY INAL B.&P.C.for this reason Over 100 A 14, N Services,Swbd.,MCC&Panelboards 0- 200 Amp.Under 600 V Signature l/ 201 - 1000 Amp.Under 600 V 29 0 4.8 A ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V # 0 0 0 0 0 2 SINGLE FAMILY Temp.Power Pole& Appurtenances l - - 25.50 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 o 0 0 25.50 v for the following reason(Section 7031.5,Business and Professions Code): 171711 Misc.Conduits &Conductors 0 22 5"8 8 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) , 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.CJ. _ PLAN CHECKING FEE Lender's Name �z PERMIT ISSUING,FEE (/ Lender's Address I certify that I have read this application and state that the above TOTAL FEE � 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. a SEE REVERSE FOR EXPLANATORY LANGUAGE —4 Z'Zp o O Signature of Permittee Date WORKERS'COMPENSATION DECLARATION -663 10/81 APPLICATION FOR ELECTRICAL PERMIT �I thereby`�f;r�-fn that 1-have a certificate of consent to self insure, CE-806G op R eertificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereo((Sec.3800,Lab. C.) fl Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ Certified Apy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS � ❑ OL2-Family, Sq.Ft. gJ L $ — $ LOCALITY Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. NEARESTCROSS ST. Date Applicant Residential Swimming Pools OWNER OR FIRM NAME �p y� ►r Pi A CERTIFICATE OF EXEMPTION FROM WORKERS' -�Li Q MAIL COMPENSATION INSURANCE Outlets:Rec ght Sw. 3 ADDRESS (This section need not be completed if the work involved by theFirst 20 permit is for one hundred dollars($100)or less.) Total No. 6 Q Additional CITY `y`�1,��l� Tel.NoZ13._6l+1�g I certify that in the performance of the work for which this permit PLAN CHECK 'APPLICANT 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 Total No. / I Z Additional CITY Tel.No. I-/ _J Date Applicant S/_ Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this 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 provisions or this permit shall be deemed revoked.' Top FAU L W.H. _ LICENSED CONTRACTORS DECLARATION Hood � Fan Other CITY Tel.No. I hereby affirm that I am licensed under provisions of Chapter 9LICENSE OR (commencing with Section 7000) of Division 3 of the Business and Disp. Room Air Cond. REG.NUMBER —� Class. Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. � ,y PROCESS Size& Type HP,•KW,KVA,or KVAR L U O License Number Lic.Class Al Up to 1 Inc[. FINAL (� Contractor Date Over 1 to 10 Incl. DATE % VAL ION O Over 10 to 50 Incl. FINAL F— ❑ I am exempt under Sec. Over 50 to 100 Inc. BY U B.&P.C.for this reason Over 100 /V/ Services,Swbd.,MCC& Panelboards Cl)FU Date.' 0-200 Amp.Under 600 V i 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 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): 9 1 5.8 A (V Misc.Conduits& Conductors o 0 0 0 0 jai I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) � 2 is not intended or offered for sale (Section 7044, Business and Professions Code). , o.08250 CONSTRUCTION LENDING AGENCY '0 0 0 8 'L 5 O 5 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 1 4'-�-8 8 Civ.C.). PLAN CHECKING FEE Lender's Name lO PERMIT ISSUING FEE Lender's Address —17 I certify that I have read this application and state that the above TOTAL FEE 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 Signature of Permittee Date