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HomeMy Public PortalAbout6120 GOLDEN WEST AVE_Electrical__ WORKERS'C4DMPENSATION_D�CLARATION 76-663 -.1 tf)/8`t • CE-806G APPLICATION FOR ELECTRICAL PERMIT -1 hereby affirm that I have a certificate of consent to 5elf.insur<; or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY cppy thereof(Sec. 3800,Lab. C.) e,. POIiCy NO. Company FOR APPLICANT TO FILL IN JOB ;t777772',� L 3r� ❑ Certified copy is herebyfurnished. EACH NO. FEE ADDRESS New Residential Bldgs.& Pools ❑ 1 & 2-Family, Sq.Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection department. Multi-family Sq. Ft. — NEAREST CROSS ST. Date Applicant Residential Swimming Pools OWNER OR 5-yay �/ x COMPENSATION INSURANCE ' FIRM NAME C. CERTIFICATE OF EXEMPTION FROM WORKERS' �� MAIL v Outlets:Rec Light Sw. o (This section need not be completed if the work involved by the First 20 ADDRESS permit is for one hundred dollars($100) or less.) Total No. Additional CITY Tel. No. v I certify that in the performance of the work for which this permit PLAN CHECK APPLICANT is issued, I shall not employ any person in any manner so as t become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Date pplint Fixed Appliances Not Over 1 HP Total No. CITY Tel. No. Tca NOTICE O APPLICANT: If, after ma this Certificate of PERMIT Exemption,you should become subject to th orkers'Compensation Range_ Heateri D.W. _ APPLICANT provisions of the Labor Code, you must to hwith 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_ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. b LICENSE OR (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Class. Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROC154SED BY �) Size& Type HP, KW,KVA,or KVAR �d� License Number 9 Lic.Class ( Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE VALIDATION Contractor � T Date Over 10 to 50 Incl. O ❑ ' FINAL V I am exempt under Sec. Over 50 to 100 Inc. BY W BAP.C.for this reason Over 100 Ll. Services,S d CC& Panelboards ® �� Cl) Date: 200 AgV Under 600 V \�/� ,2 Signature 2 000 Amp.Under 600 V Over 1000 Amp.or Over 600 V � ❑ Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole & Appurtenances !/`r HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ff ; r I hereby affirm that I am exempt from the Contractor's License Law additional Sign Branch Circuits ACCT°f for the following reason(Section 7031.5, Business and Professions Code): ur ❑ 'r I,as owner of the property,will do the work and the structure Misc.Conduits & Conductors 1 ITEMS is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , , 50 and Professions Code). pool TOT AL .a.,�' - CONSTRUCTION LENDING AGENCY CHECK 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 -i i1le ?f Lender's Name 0 ll 8/2 PERMIT ISSUING FEE � t Lender's Address - 2'''��i 6 1 AM 9:'`'� 1 certify that I have read this application and state that the above TOTAL FEE 35 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 in ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE c" z,-- Sig re of Per e CDate WORKER S'COMPENSATION DECLARATION -CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES AND SAFETY ink rd`or a certificate of Workers'Compensation Insurance,or ( ,/ �� u a certifies copy thereof(Sec. 3800,Lab. C.) �/ G' FOR APPLICANT TO FILL IN SOB c ) ��1 Policy No. Company ADDR S �� N. (4-0 ldedl e_5 New Residential Bldgs.&Pools EACH NO. EE D Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY "T" J--NE Multi-family Sq. Ft. CROSS ST Certified copy is filed with the county building inspection department. Residential Swimming Pools F OWNER OR yy GG � I 6. r �� Date . Applicant Outlets: Rec.JkLight�Sw.� MAIL FIRM NAME/E' ' VJJ First 20 ADDRESS 61 O q� es CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.A Additional CITY Tel No. .,. e } COMPENSATION INSURANCE PLAN CHECK CL APPLICANTO (This section need not be completed if the work involved �' U by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS Additional cc I I certify that in the performance of the work for which this Total No. CITY Tel No. 0 Fixed Appliances Not Over 1 HP U permit is issued, I shall not employ any.person in any manner PERMIT W so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT d Oven _ Dryer_W.M. ADDRESS toZ Date Applicant Top FAU _W.H. Hood Fan _Other_ CITY Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond._ LICENSE OR Exemption, you should become subject to the Workers' REG. NUMBER Class Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO. PR ES ED BY with comply with such provisions or this permit shall be deemed revoked. Size&Type HP, KW, KVA,or KVAR Up to 1 Incl. lJ FINAL LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE VALIDATIO Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY ness and Professions.Code, and my license is in full force and effect. Services V'�� License Number Lic.Class 0-200 Amp�nder 600 V 201-1000 Amp. Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole& Appurtenances Sign with One Branch Circuit a I hereby affirm that I am exempt from the Contractor's it h Cir n Sign B Si gBranch Circuits c License Law for the following reason (Section 7031.5, Busi- Additional ness and Professions Code): 29 4 8 5,0 A Misc.Conduits&Conductors X I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 0 0 0 0 0 2 structure is not intended or offered for sale (Section 7044, Business and Professions Code). 2 9 0 2 6 5 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency o o o .2 6 5 00' for the perfortnance of the work for which this permit is PERMIT FEE (Sub-Total) ` issued (Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 0 4,2 0781 Lender's Address PERMIT ISSUING FEE 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 above-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of P ittee Date WORKERS' COMPENSATION DECLARATION oPw3ie7 76A663 APPLICATION FOR ELECTRICAL PERMIT O 76 4 • :d y affirm that I have a certificate of consent to self CE-806-806 6 insure or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 'or g certified copy thereof (Sec. 3800, Lab. C.) r- Policy'No. Company FOR APPLICANT TO FILL IN JOB " ! ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ,� 70 C.. $ _ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ LOCALITY PLG, C( tion department. Multi-family Sq. Ft. NEAREST Residential Swimming ols CROSS ST. Date Applicant - OWNER OR5- FIRM NAME AL CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light Sw. MAIL COMPENSATION INSURANCE ADDRESS ` 2 First 20 (This section need not be completed if the work involved by Total No. Additional CITY Tel. NUS-el�,Z� the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in he performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner sous to become subject to the Worker 'Com ens i 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 Heater—D.W. APPLICATION _ , Exemption, you should become subject to the Workers' Range— Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS a nc t with comply with such provisions or this permit shall be Top FAU —W.H. — deemed revoked. CITY C Tel. No. 2S LICENSED CONTRACTORS DECLARATION Hood — Fan —Other— Dis _ Room Air Cond. — LICENSE OR �r I hereby affirm that I am licensed under provisions of Chapter 9 p REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCES BY >- and Professions Code,and my license is in full force and effect. t1 Size &Type HP, KW, KVA, or KVAR v 0 License Number Lic. Class Up to 1 Incl. FINAL V Over 1 to 10 Incl. DATE V ATION Contractor Date 0 ❑ Over 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. By U LU B.&P.C. for this reason Over 100 � Date: Services, Swbd., MCC& Panelboar 000,0-200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V ��� ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V G SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 9 9 3.4 A Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors # o o.,o e 2 structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— , ( o o ](( Q Business and Professions Code). CONSTRUCTION LENDING AGENCY o o o 7 4,0 Q,= 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) 0-6.2.0-8 8 (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name A 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 abo -ment'oned roperty for nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE &�. ,2�o ©s Signature of Permittee ` Date