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Home My Public Portal About5528 GOLDEN WEST AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 10i81 APPLICATION FOR ELECTRICAL PERMIT � 1, lierqby, affirm that I have a cer�ficate of consent to self CE-806G jnsure, o a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY C61,clcertified copy thereof (Sec. 3800, Lab. C.) d( Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS S 5 'z $ N e S Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH PNO. FEE ❑ $ LOCALITY Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. 3000 $ tion department. Multi-family Sq. Ft. NEAREST CROSS ST. 1Sr6A \ A Residential Swimming Pools OWNER OR Q, Dale_ Applicant -FIR M NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:•Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS First 20 (This section need not be completed if the work involved by Total No. Additional CITY Tel. No. 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 any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel. No. Date 10I1-48-) Applicant A��4 Y�-C. C' Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT `�CAQ r� E�/ 2� 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 ? S W01 with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. Hood Fan _ Other_ CITY Avcaz,I fA CA 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 3Z-5V8 Class.0(0 (commencing with Section 7000) of Division 3 of the Business DISTRICT IN PRO ES ED BY >_ and Professions Code, and my license is in full force and effect. Power.Apparatus& Large Appliances G ; &�, p Size &Type HP, KW, KVA, or KVAR' 0 License Number..32.4'0 C)6 Lic. Class C_ 10 Up to 1 Incl. FINAL Y+M�CA►a Date��'t3�$7 Over 1 to 10 Incl. DATE D VALIDATION � Contractor Over 10 to 50 Incl. FINA a ❑ I am exempt under Sec. Over 50 to 100 Inc. BY - MR Over 100 B.&P.C. for this reason 8 1 1. A #A Date: Services, Swbd., MCC & Panelboards 0 - 200 Amp. Under 600 V # o o o a o2. Signature 201 - 1000 Amp. Under 600 V ° 1 3 Q 5 0 El Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. ' _ SINGLE FAMILY Temp. Power Pole &Appurtenances ° ° 1 3.Q 5 Q v HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit FI 1 5 -87 I hereby affirm that I am exempt from the Contractor's License Q Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): ❑2 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)_ 7044, Business 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 PERMIT FEE (Sub-Total) (Sec. 3097, 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 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 ove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 10—t3— 7 Signatur of Permittee Date Wfirm that COMPENSATION DECLARATION CE-806 ,D,B, 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 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 55 p 1,e ,-f— S Ft. $ — $ LOCALITY Certified copy is filed 1 & 2-Famil with the county building inspec- Y- q tion department. Multi-family Sq. Ft. NEAREST CROSS ST. Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight Sw._, MAIL g� T4 S COMPENSATION INSURANCE First 20 ADDRESS (This section need not be completed if the work involved by Total No. CITY-5 •(�, Tel. No.Z$S the permit is for one hundred dollars ($100)or less.) Additional �� I certify thatin the performance of the work for which this PLAN CHECK P APPLICANT OLtJ�✓* permit 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. Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT I. A 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 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. P IEED BY and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances r >_ Size &Type HP, KW, KVA, or KVAR <0 0 License Number Lic. ClassUp to 1 Incl. FINAL i V Over 1 to 10 Incl. DATE Contractor Date VALIDATION ftg ❑ Over 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. BY g / i �/ B.&P.C. for this reason Over 100 in� "—` � Date: Services, Swbd., MCC & Panelboards 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 I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the Ilowing reason (Section 7031.5, Business and Prof ns 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)_ 7044, Business and Professions Code). r 2 7 3 77 A CONSTRUCTION LENDING AGENCY # o o o o,o 2 1 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) 2550 (Sec. 3097, Civ. C.). PLAN CHECKING FEE o.o o 2 5 5.0:5 Lender's Name PERMIT ISSUING FEE o f 0 630-87 Lender's Address I certify'that I have read this application and state that the TOTAL FEES above infor ation is correct. I agree to comply with all County ordinance and State ws regulating Electrical wiring, and hereby thorize r entatives of this County to enter upon the a-men 'o roperty for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 3� g g ure o ittee I Vate