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HomeMy Public PortalAbout5838 GOLDEN WEST AVE_Electrical__ �1 `N/CSRKEftS'COMPENSATION DECLARATION 76A66goPwaie7 APPLICATION I'�R ELECTRICAL PERMIT J t bier y. Lfirm that I'have a certificate of consent to self CE 806G gn$ure, or a certiflnte of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS pr a,cer:if§ed=Eepy hereof (Sec. 3800, Lab. C.) Policy No. •+ Company FOR APPLICANT TO FILL IN JOB ❑Certif ed copy is hereby furnished New Residential Bldgs. & Pools EACH NO. FEE ADDRESS3� L/ nJkJe�j� - ❑Certified copy is filed with the county-building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. Ft. NEAREST CROSS S Date Alicant Residential Swimming Pools OWNER OR PP FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec2-LLight 11 ,,Sw. MAIL COMPENSATION INSURANCE S ADDRESS 5,41,6. il First 20 (This section need not be completed if the work involved by Total No. Additional f3 CITY %A —C Tel. No�/�ZJV63, the permit is for one hundred dollL100) ss.)I certif that in the erformance owhich t is PLAN CHECK Y P APPLICANT permit is issued, I shall not employny m ner Lighting Fixtures First 20 ADDRESSso as to b come subject to the Wo ati aws. e� Additional Total No. CITY Tel. No. Date Applican Fixed Appliances Not Over 1 HP PERMIT NOTICE TO A PLICANT: If, after making this Certificate of APPLICATION NY Exemption, you should become subject to the Workers' Range— Heater—D.W. Compensation provisions of the Labor Code, you must forth- Oven — Dryer T W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU W.H. — deemed revoked. CITY Tel. No. Hood Fan —Other LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. REG. NUMBER Class. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. , PROCESSED BY�/ 1 d and Professions Code,and my license is in full force and effect. r,� Size &Type HP, KW, KVA, or KVAR ✓ v ((� O License Number Lic. Class Up to 1 Incl. FINAL C) Over 1 to 10 Incl. DATE VALID ION 0 Contractor Date Over 10 to 50 Incl. FINAL / ~ ❑ I am exempt under Sec. Over 50 to 100 Inc. BY ! U LLJ B.&P.C. for this reason Over 100 d ' d Services, Swbd., MCC & Panelb�rds / el , ��i ,�}J #42 2 0'3 9 8 A Z Date: 0-200 Amp. Under 600 V4 (el l �V l e' Signature 201 - 1000 Amp. Under 600 V r7 0 0 0.0 0 2 ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V I o - 6,1,75 SINGLE FAMILY Temp. Power Pole &Appurtenances ° O 6 1,7 5 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 0 8, 1 .0+�8 8 I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): Eli, as owner of the property, will do the work and the Misc. Conduits& Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ 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 f /,-7 above ' formation is correct. I agree to comply with all County ordi nc s and State I ws regulating Electrical wiring, and he by o h. -e repr sentatives of this County to enter upon t ab �e-ment' property fo spection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE �� Signature of ermittee ate ©s WORKERS' COMPENSATION DECLARATION CE-806 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 or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ,r Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 4 V L lVE-5T r CIL- S — Certified copy is filed with the county building inspec- 1 & 2-Family, 9• Ft. $ $ LOCALITY tion department. Multi-family CRNEAREOSS ST ST. $ T&4. Residential Swiwi mmm ing Pools_ OWNER OR �!pp7���� ��? Date Applicant FIRM NAME GiZ 6 Lam.• CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE first 20 ADDRESS (This section need not be completed if the work involved by Total No. Additional. CIT Gr Tel. No.p�� d 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 p Fon in any manner \, so as to become subject to the Wor ompensati Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional � A CITY Tel. No. Date Applicant Fi ed Appliances Not Over 1 HP PERMIT NOTICE/T6 APPLICANT: If, after making this Certificate of APPLICANT Exemption, you should become subject to the Workers' Range_ Heater—D.W. — Compensation provisions of the Labor Code, you must f - Oven — Dryer — W.M._ ADDRESS with comply with such provisions or this permit shall be Top FAU —W.H. — IL deemed revoked. Hood Fan _ Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR II 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 SED BY a and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances Q� ^ O Size &Type HP, KW, KVA, or KVAR' U License Number Lic. Class Up to 1 Incl. FINAL J� 0 Over 1 to 10 Incl. DATE VALIDATION � Contractor Date H ❑ Incl.Over 10 to 50 FIN W' I am exempt under Sec. Over 50 to 100 Inc. BY Over 100 B.&P.C. for this reason -1 Z Date: Services, Swbd.,"MCC & Ponelboards 0 - 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Exemption 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 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 5'4 Q'1 Al ra essions Code): # © o 0 00 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)_ , '( o - 2S50 7044, Business and Professions Code). o o o2550'0' CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for 0 Q� 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 �v 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 her uthorize repr, senI tives of this County to enter upon th e-men io property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of er ittee ate