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Home My Public Portal About6129-6131 GOLDEN WEST AVE_Electrical__ 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 T BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab. C.) > FOR APPLICANT TO FILL IN JOB ``' w ti Policy No. ®�/ /ompany '� EACH NO. FEE ADDRESS /✓, G-0 �^ New Residential Bldgs.& Pools r s/ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft.�/moi_ $ — $ �� LOCALITY Multi-family Sq. Ft. — NEAREST �fied copy is filed with the county building inspection CROSS ST department. �� Residential Swimming Pools OWNER OR Ier�/3C-� FIRM NAMEA40-1- Date licant �Y�e MAIL " PP Outlets: Rec.—Light—First ADDRESS - D First 20 CERTI KATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY r Tel No� COMPENSATION INSURANCE } PLAN CHE O. (This section need not be completed if the work involved APPLICANT O by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS U Total No. Additional cc I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. O permit is issued, I shall not employ any person in any manner PERMIT U so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANTW Oven _ Dryer_W.M. ADDRESS N to Date Applicant Top _ FAU _W.H.. Z 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 _L0 Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. P`ROCES ED BY with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR t7 deemed revoked. / Up to 1 Incl FINAL _ � ! ,� LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE VALIDATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 ness and Professions Code, and my license is in.full force and effect. Services License Number. Lic. Class es 0-200 Amp. Under 600 V 4 Of 201-1000 Amp. Under 600 V �y / Contractorlets P �/ite 2 Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits ness and Professions Code): J'5 7 8 4 A Misc.Conduits&Conductors I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— ° ° ° 0 0 2 structure is not intended or offered for sale (Section 7044, Business and Professions Code). 2 6 1 3 2 7 0 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ° ° 1 3 2 7 0 x for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued (Sec. 3097,Civ.C.). /a A0 0823-82 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE L) I certify that I have read this application and state that the TOTAL FEE /,3 2—70 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 ove- en ' ed propert for in pection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE nature of ermittee ate WORKERS'COMPENSATIONDECLARATION CE8606G (2-B0) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have•a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,L C.) . G.s JOB Policy No. Company LG` FOR APPLICANT TO EACH FILL N NO. FEE ADDRESS /�� New Residential Bldgs.&Pools _ � El Certified copy is hereby fu ' hed./ 1 &2-Family,Sq. Ft. $ $ LOCALITY Multi-family Sq. Ft. — NEAREST �Certified copy is filed with the county building inspection CROSS ST epartment. Residential Swimming Pools OWNER OR FIRM NAME Date Applicant Outlets: Rec.—Light Sw. ADDRESS (J(� 3� First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. AdditionalCITY (� Tel No. COMPENSATION INSURANCE r� � PLAN CHECK D. (This section need not be completed if the work involved APPLICANT O by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS y> Total No. Additional O /�- Tel No. All, 0 Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any manner PERMIT y W so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT �'T '7I T(r- O. Oven _ Dryer_W.M,. ADDRESSG''� ^'' to Date Applicant Top _ FAU _W.H. Hood _ Fan _Other_ CITU '7; Tel Nos 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 _ 7_) Z_4Class ^� Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. 7%�� with comply with such provisions or this permit shall be Size&Type HP, KW, KVA,or KVAR �� deemed revoked. Up to 1 Incl. Over 1 to 10 Incl. FINALDATE ,.- LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. Z VALIDATION 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 6f� License Number Lic.Class 0-200 Amp. Under 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 I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit Additional .1:a License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits ness and Professions Code): to o,o o'o '� Misc.Conduits&Conductors I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— �.0>0.2,0.5 0 structure is not intended or offered for sale (Section 0 040 2 O,Jr 0 v 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agencyO S 2 5'—8 2 for the performance 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) 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 abo - ntioned17rAerty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ittee Date