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HomeMy Public PortalAbout5757 GOLDEN WEST AVE_Electrical__ p �9. ( ..,WORKERS'COMPENSATION DECLARATION C 10/81 APPLICATION FOR ELECTRICAL PERMIT I#lereby gfSirm that I have a certificate of consent to self insure, A CE-806G or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY 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 ADDRESSk �.e ' ❑ 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. CROSS ST. L a 3yL Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets:Rec Light t 2 — ADDRESS This section need not be completed if the work involved b the First 20 ( p y Total No. Additional CITY Tel.No. permit is for one hundred dollars($100)or less.) • PLAN CHECK I certify that in the performance of the work for which this permit 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. Additional CITY Tel.No. Datrn�'�' �� Applicant Total Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT�CI �li3 Y cif Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. provisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESS,�45d provisions or this permit shall be deemed revoked. Top FAU W.H. r e ClT Tel.No ��✓t� LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ I hereby affirm that I am licensed under provisions of Chapter 9 E oR (commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. _. REG.REG.NUMBE t, Class. Professions Code,and my license is in full force and effect. Power A DISTRICT NO. PROCESSED pparatus& Large Appliances r _ / Size& Type HP,KW,KVA,or KVAR f v p License Number 3-A l /-2, Lic.Class � 0 _L Up to 1 Incl. FINAL j U .% -4 r 2 —f Over 1 to 10 Incl. DATE Contr�c,tetat'l aYe, VALIDA N Over 10 to 50 Incl. V FINAL.; ❑ I am exempt under Sec. Over 50 to 100 Inc. BY W Over 100 B.&P.C.for this reason ; fn Services,Swbd.,MCC& Panelboards Z Date: 0-200 Amp.Under 600 V 2 8 9 Q 4 A Signature 201 - 1000 Amp.Under 600 V Over 1000 Amp.or Over 600 V # 0 0 0 0.02 ❑ Exemption for Reg.Maint.Elect. I ° ° 1600 SINGLE FAMILY Temp.Power Pole& Appurtenances HOME OWNER-BUILDER DECLARATION0 0 o 16005 Sign with One Branch Circuit 1 hereby affirm that I am exempt from the Contractor's License Law O 2 O 3 0 8 for the following reason (Section 7031.5,Business and Professions Additional Sign Branch Circuits Code): ❑ Misc.Conduits&Conductors I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) is not intended or offered for sale (Section 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(Sec.3097, PERMIT FEE (Sub-Total) 556 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 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 Permie Date 0 WORKERS'COMPENSATION DECLARATION zo-ool9DPW 3ie7 APPLICATION- FOR ELECTRICAL PERMIT I hereby(affirm that I have a certificate of consent to self CE a06G �nsurap, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS *c i` a certified copy thereof (Sec. 3800, Lob. CJ Policy No. Company FOR APPLICANT TO FILL IN JOB r+' 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 _ '. tion department. Multi-family Sq. Ft. NEAREST' ' Residential Swimming Pools CROSS ST. Date Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS'' Outlets: Rec5"_ Light—I—Sw.L MAIL COMPENSATION INSURANCEFirst 20 / �D ® ADDRESS (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 ? 07 so as to become sub- ct to the Workers'Compensation.Laws. Lighting Fixtures First 20 .� 70 ADDRESS Additional , i'! Total No. CITY Tel. No. Date �+ Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION 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 Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY >_ and Professions Code,and my license is in full force and effect. a Size& Type HP, KW, KVA, or KVAR O License Number Lic. Class Up to 1 Incl. FINAL U Contractor Date Over 1 to 10 Incl. DATE VALIDATION 121O Over 10 to 50 Incl. FINAL O I am exempt under Sec. Over 50 to 100 Inc. BY r ✓ W B.&P.C. for this reason Over 100 Services, Swbd., MCC& Ponelboards ZZ Date: 0- 200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V El Exemption 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION - I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Sign Branch Circuits Si Law for the following reason (Section 7031.5, Business and Additional9 Professions Code): Misc. Conduits&Conductors VhJ I, as owner of the property, will do the work and the structure isnot intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Professions Code). , _ � pq r' -r•,; - 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 tr �3 D� 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 4 1 Aresentatives of this County to enter upon the abov -men' d property for inspection,purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s -Signa re of Permitte Date ' WORKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT L CE-806G MeVoy.affirm that I have a certificate of consent to self insure, of -,"cerfificate of Workers' Compensation InS rance, or certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab.C.) --- - - - - Policy No. Company, ' FOR APPLICANT TO FILL IN JOB (I�TmJEACH NO. FEE ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools ❑ 1 & 2-Family,Sq.Ft, $ _ $ LOCALITY Certifieopy is filed with c unty building inspection NEAREST t. r /j Multi-family Sq.Ft. (//'lel' CROSS ST. Date Appli n Residential Swimming-Pools OWNER OR ? FIRM NAME A C/ ERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets:Rec Light Sw. O / �- ADDRESS (This section need not be completed if the work involved by theFirst 20 Total No.� Additional QU, CITY Tel.No. permit is for one hundred dollars($100)or less.) - I certify that in the performance of the work for which this permit PLAN LPLICHE is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures p First 20 O ADDRESS Additional Total No CIT Tel.No. Date Applicant Fixed Appliance Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PLIC / Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ PLICA Tr 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. CITY Tel.No. LICENSED-CONTRACTORS DECLARATION Hood _ Fan Other_ �-7l I hereby affirm that 1 am licensed' under provisions of Chapter 9 Dis — Room Air Cond. - v LICENSE OR yr 71, Class. (commencing with Section 7000)of Division 3 of the Business and p REG.NUMBE 1 c� Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. r P CESSE Y Size& Type HP,KW,KVA,or KVAR License r �d Lic.Class All Up to 1 Incl. FINo/l A V Over 1 to 10 Incl. DATE VALIDATION 0- Con t Date❑ Over 10 to 50 Incl. V FINAL I am exempt under Sec. Over 50 to 100 Inc. BY 1.1 Over 100 C- BAP.C.for this reason ( f Z Services, Swbd.,MCC&Panelboards ` _ , / Dat 0- 200 Amp.Under 600 V ! (/ Signat 201 - 1000 Amp.Under 600 V ❑ - Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. ;28737A SINGLE FAMILY Temp.Power Pole& Appurtenances # 0 0 0 0 0 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ­5250 1 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 o 0 0 5250 Code): ❑ I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , and Professions Code). o1, 1 1 -88 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. 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 above TOTAL FEE information is correct. I agree to comply with all County ordinances and State laws regulating Ele 'cal wiring, and hereby authorize re ��sentatives of this Coun to ent upon the above-mentioned roer for inspect'f,pur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE I/14Wf1T__11_D ignature of Per i tee / / e