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HomeMy Public PortalAbout6114 GOLDEN WEST AVE_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT " I he,pb) affirm that I have a certificate of consent to self CE-806G 7� i.4, , or certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY 'ul or a certified copK thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN ADDRESS / 11�(�(J W c�.�� JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE 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 , 5 FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light. Sw MAIL COMPENSATION INSURANCE Z ADDRESS This section need not be com leted if the work involved b First 20 ( P Y Total N � Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) that in the performance of the work for which this PLAN CHECK I certify P APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Worker 'Co pen t' Laws. Lighting Fixtur First 20 ADDRESS Total No. Additional ` CITY1AMYL -r- Tel. No. �© Date Applicant Fixed Appliances of Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making thYCertificate of APPLICANT 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. -25L kvr- 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. Class. REG. NUMBER (commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT� PROCESSED BY Cl. and Professions Code,and my license is in full force and effect. U Size &Type HP, KW, KVA, or KVAR' License Number Lic. Class Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE i Contractor Date V LIDATION ❑ Over 10 to 50 Incl. FINAL W I am exempt under Sec. Over 50 to 100 Inc. BY n B.&P.C. for this reason Over 100 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 5 0 9.0 A SINGLE FAMILY Temp. Power Pole & Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # o 0 o o 0 2 1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits o 0 2 Q Q Law for the following reason (Section 7031.5, Business and Pr essions Code): o 0 0 2 a Q Q Misc. Conduits&Conductors I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , 0 7,2.1 :°8 6 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) D (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 th4abb e-mention d � operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P,-4Aittee Date WORKERS'. Ihave COMPENSATION DECLARATION CE-806 1081 APPLICATION FOR ELECTRICAL PERMIT \ I 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 co is hereby furnished. EACH NO. FEE ADDRESS PY Y New Residential Bldgs. & Pools ❑ 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. OWNER OR Date_ pplicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS This section need not be completedFirst 20 ( if the work involved b Y Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) I certifythat in the performance of the work for which this PLAN CK P APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Work rs'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel. No. ate Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO 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 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 O 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. PROCES D BY and Professions Code, and my license is in full force and effect. Size &Type HP, KW, KVA, or KVAR- O License Number Lic. Class Up to 1 Incl. FINAL 7 U 09 Over 1 to 10 Incl DATE X — �2—�a_ VALIDATION U Contractor Date Over 10 to 50 Incl. u v FINAL I am exempt under Sec. Over 50 to 100 inc. BY s B.&P.C. for this reason Over 100 v g 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 "9 3 1. 1 A' 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 i'f u v 0 0 0 2 Professions Code): ❑ 2 0'0 I, as owner of the property, will do the work and the Misc..Conduits & Conductors 2 5 50 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 7044, Business and Professions Code). 0 CONSTRUCTION LENDING AGENCY 030 ✓, Q 1 -84 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 FEEj 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 a�be-mentioned property�forspection pu/rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ature of Permittee Date WORKERS'COMPENSATION DECLARATION CE-806 lD/Bl 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 �sr Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS , ❑ 1 & 2-Family, S Ft. $ r;t, $ NEARELOCALITYCertified copy isfiled with the county building inspec- y• q�tion department. Multi-family Sq. Ft CROSSSST.Date Applicant Residential Swimming Pools OWNER OR NAMECERTIFICATE OF EXEMPTION FROM WORKERS' �,Outlets: Rec �� Light�Sw. MAILCOMPENSATION INSURANCEADDRESSFirst 20r� ' -o (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 Worke'r�''Compensat' ws. Lighting Fixtures First 20 D ADDRESS /) ��Z. C'%s� Total No. Additional CITY Tel. No. Date "I Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this ertificate of APPLICANT Exemption, you should become subject to the Workers' Range_ Healer 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 J_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. PROCESSED BY Power Apparatus& Large Appliances and Professions Code,and my license is in full force and effect. Size &Type HP, KW, KVA, or KVARO License Number Lic. Class Up to 1 Incl. FFINA L �" %) Over 1 to 10 Incl. `y/ VALIDATION Contractor fte Date Over 10 to 50 Incl. L❑ I am exempt under Sec. Over 50 to 100 Inc. p Over 100 B.&P.C. for this reason ri Services, Swbd., MCC & Panelboards Date: 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 ti o o 0 0 0 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License 2u qo yo ! _ Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits U Y Ii GJ Yons Code): U Y 4 as owner of the property, will do the work and the Misc. Conduits& Conductors r 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 C 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 b , e-mentioned ty f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pe tee Date 1 I