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HomeMy Public PortalAbout6030 GOLDEN WEST AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76A669DPW 3iaz APPLICATION FOR ELECTRICAL PERMIT O y� I hereby affirm that I have a certificate of consent to self ,cEaoaG insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS orn Certified copy thereof (Sec. 3800, Lab. C.) Policy No 52 2- Company � ,!:,r.--.O FOR APPLICANT TO FILL IN JOB j� ❑Certified co is hereby furnished. G EACH NO. FEE ADDRESS 630 `6 Lll PY Y �- y- /� New Residential Bldgs. tt&'�Poo�ool—ls��� Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. _ $ LOCALITY Lam. C i n department. Multi-family Sq. Ft. NEAREST CROSS ST. lr C ✓ /9t t— ?/ L Residential Swimming Pools OWNER OR Date Applicant FIRM NAME �jJ O6y S CERTIFICATE OF EXEMPTION FROM W RKERS' Outlets: Rec Light ' Sw._ MAIL COMPENSATION INSURANCE First 20 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 so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No.' CITY Tel. No. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION - w` fG 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 _✓7b IL ( Tel. No. p 23n) LICENSED CONTRACTORS DECLARATION Dis — Room Air Cond. LICENSE OR ` I hereby affirm that I am licensed under provisions of Chapter 9 P REG. NUMBER �/ jf Class. C /6 (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. P O ESSED BY >_ and Professions Code,and my license is in full force and effect. f)�/ d L e-/ 6 Size &Type HP, KW, KVA, or KVAR �JO Q License Number Lic. Class Up to 1 Incl. FINAL U 7—eq-1 r� �L� .r`G C- Over 1 to 10 Incl. DATE VALIDATION 0 o tractor / Date Over 10 to 50 Incl. !� I- ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. U BY W B.&P.C. for this reason Over 100 a Services, Swbd., MCC & Ponelboards Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp, or Over 600 V Exemption for Reg. aint. Elect. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances I hereby P affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Additional Si s n Branch Circuits r3 Law for the following reason (Section 7031.5, Business and 9 Professions Code): ;' i 7C_. __x_. _.. ❑ Misc. Conduits& Conductors + T1-,—*:-I, as owner of the property, will do the work and the I I I Cl 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 L ; the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) '•` A `E (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Namehl + iL a, f;aC.1 PERMIT ISSUING FEE DO . Lender's Address N � s j-,;�:,p� 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 ve-mentioned propy for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE - _? Zo 9 / ©s S gnature of ermi tee Date WORK1`RS' COMr'ENSATION DECLARATION 76A663 10/81 ` CE-806G APPLICATION FOR ELECTRICAL PERMITh�reok%,-rm'that I hav? a certificate of consent to self insure, ;3 certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY u `P�py'(hereof( ec.r8800,Lab. C.) .ILS Y, ftr.� Poli_j1.(o 4�� ` 7ompanyIV N��� �pK` FOR APPLICANT TO FILL IN JOB y� ,/�p ❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS �30 G o t d co (U X57 New Residential Bldgs.& Pools 1 & 2-Family,Sq. Ft. $ — $ LOCALITY ❑ Certified copy is filed with the county building inspection — NEAREST p irttt�ne t. e� --�.yN�.. �d{ Multi-family Sq.Ft. CROSS ST. J a ] Date i' �� �✓ App'Pn °a Z4 �V� r�G ��� Residential Swimming Pools FIRM NAME Edd it �c jc1�/Z/a t, 1�u) t CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light — Sw. — MAIL ,.q �CRda� f���� COMPENSATION INSURANCE First 20 ADDRESS llOO V�+ , (This section need not be completed if the work involved by the CITY e- L permit is for one hur(dred dollars($100) or less.) Total No. Additional {RC 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 Additional •. Total No. CITY Tel.No. ' Date Applicant Fixed Appliances Not Over 1 HIP ' PERMIT •�J. t NOTICE TO APPLICANT: If, after making this Certificate of APPLICANTU NITC / W CI /1'�� 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._ ADDRESSL d Vt ') ,6e,ULiaNd provisions-or this permit shall be deemed revoked. Top — FAU W.H. CITY �,1 ®� � el i�o-���6,�3`� LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ I hepeby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR - Class. (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. power Apparatus& Large AppliancesIS' DISTRICT N�7��)J ` ' PROCE BY .. �pp Size& Type HP,KW,KVA,or KVAR u"+ �/V 0 License Number `� Lic.Class Up to 1 Incl. FINAL U Cony J a e Over 1 to 10 Incl. DATE VALIDATION O ❑ Over 10 to 50 Incl. FINAL V I am exempt under.Sec. Over 50 to 100 Inc. BY B.&P.C,for this reason Over 100 N Services,Swbd.,MCC & Panelboards ► Z Date: 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 0 -3307 0 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law 1 ITEEMS for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): T€ITA€. 31 = 00 ❑ I,as owner of the property,will do the work and the structure Misc.Conduits &Conductors CASH ,.r1°') f ') is not intended or offered for saleSection 7044, Business Other (See Complete Fee Schedule) , and Professions Code). ( CHANGE °0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the 0000-0001 7f40 performance of the work for which this permit is issued(Sec3097, PERMIT FEE (Sufi= Total) Civ.C.). 2a2'.6 1 �lE i fix o 1: . 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 pi ftperty in ection pkirposes. SEE REVERSE-FOR EXPLANATORY LANGUAGE �-� b SigrTature of Permitlee 0Date WORKERS' COMPENSATION DECLARATION 2o-ooteDPW sie7 APPLICATION FOR ELECTRICAL PERMIT Q I hereby,affirm that I have a certificate of consent to self CE806G 'insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEP OF PUBLIC ORKS or.a rerlifier copy thereof (Sec. 3800, Lab. C.)) Policy No. V�S� ompany G�T` FOR APPLICANT TO FILL IN JOB �s F]Certifiedcopy is hereby furnished. �j New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 0_34 �0' Sr F—Aertified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY �C tion department. Multi-family Sq. Ft. NEARESTCROSS ST. l/ Residential Swimming Pools OWNER OR Date Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM ORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 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 so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel. No. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range.— Heater—D.W. _ APPLICATION Te 1 Lel Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS —2 with comply with such provisions or this permit shall be Top FAU —W.H. — deemed revoked. CITYG 1,7 �_ Tel. No. ZI / LICENSED CONTRACTORS DECLARATION Hood — Fan —Other— Disp. — Room Air Cond. — LICENSE OR F / s Class. G. NUMBER `�( (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PZSED BY >_ and Professions Code,and my license is in full force and effect. a- � License Number < �3 y } �1�ic. Claims Size &Type HP, KW, KVA, or KVAR QUp to 1 Incl. FINAL U ' U` C b_ CIG Over 1 to 10 Incl. DATE 6 VALIDATION ontr,�ci r Date❑ 0 Over 10 to 50 Incl. FINAL. I am exempt under Sec. Over 50 to 100 Inc. BY C) LU B.&P.C. for this reason Over 100 d IV fn Date: Services, Swbd., MCC 8 Panelboards �p / p O , Z 0-200 Amp. Under 600 V O Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. MaOver 1000 Amp. or Over 600 V Mat. Elect. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole& Appurtenances I herebyaffirm that I am exempt from the Contractor's License Sign with One Branch Circuit >• •- c p Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and 9 _ Professions Code): :J_1I _'I' Ell, as owner of the property, will do the work and the Misc. Conduits & Conductors 4 TT)~ structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— , r_ 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 `?('•••VL ')'( P P (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name I__sl_l1---;,¢!1_{ PERMIT ISSUING FEE d rz x; Lender's Address s' is:` _ {�:_,';..�0�;. 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 abe-mentioned ro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of/Permittee Date ©,