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Home My Public Portal About6309 GOLDEN WEST AVE_Electrical__ WORKERS'COMPENSATIOI�DECLARATION CE-806G (2-80)CERAPPLICATIONS FOR ELECTRICAL PERMIT / I hereby affirm that I have ■ certiflcate of cornent to self COUNTY OF'.LOS ANGELES BUILDING AND SAFETY insure, or ■ certificate of Workamti Compensation Insurance,or ■cert(fled copy thereof(Sec. 3800,Lab.C.) f FOR APPLICANT TO FILL-IN JOB Policy No. ComPanYNew Resldentlel Bldgs.&Pools EACH NO. FEE ADDRESS Q Certified copy is hereby furnLhed.(- ! T&2-Famlly,Sq, Ft. ; $ LOCALITY Certlfted copy h filed wlththe coup' Multi-family Sq. Ft. CROSS ST p county building Inspection ResidentiaVgh ols department. OWNED OR FIRM NAME l5ate Applicant Outlets: ReSw.� ADDRESS Irst 20 CERTIF QATE OF EXEMPTION FROM WORKERS'. Total No. dditional CITY Tel No. } COMPENSATION INSURANCE PLAN CHECK a (This section need not be completed if the work hTvolved APPLICANT S by the permit is for one hundred dollars ($10% or len.) Lighting Fixtures First 20 ADDRESS AddlUonal Total No 0 I certify that in the performance of the work for which this CITE' Tel No. permit Y Issued, I shall not employ any person in any manner Fixed Appliances Not Over 1 HP i) w as to become sub act to the Workers' Compensation Laws. Re PERMIT W J p age_Reefer� D.W. _ P ANT Q Ovbn �Dryer]L W.M. ADDRESS V1 Z pate AppUcant Top FAU _W.H. Hood Fen _Other_ CITY N. NOTICE TO APPLICANT: If, after.making this Certificate of Disp. I:ioom Alr Condom R Exemption, you should become sub)ect to the Workers' REG,NUMBER Class Compensation provision of the Labor Code, you must forth- Povvelr Apparatus& Large Appliencea DISTRICT NO�� PR CE D BY with comply with such provisions or.this permit shall be Sire&Type HP,KW, KVA,or KVA deemed revoked. f/�rj' Up to 1 Incl. FINAL Over 1tv 10 Incl. DATE A -� VALIDATION LICENSED CONTRACTORS DECLARTION Over 10 iro 60 Incl. I hereby affirm that I am•Rcensod under provision of Chapter Over 60 to?1.001nc. FINAL G BY a Qf 9 (commencing with Sectlon'7000) of Division 3 of the Basi- � Over 100 ness and-Professions.Code, and my license is in full force and effect. Servlces Llcerue Number L1c.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. Powgr Pole&Appurtgnances Sign With One-Branch Circuit £O'6 9,O'A I hereby r,ftlrm that I am exempt from the Contractor's AddWonal Sign Branch Circuits License Law for the following reason (Section 7031.5, Busi- # o o 6 o o 2 nen and Professions Code):' . �r Mlsc.'Condufts�Conductors I, as owner of the property, wdo the work and the, Other (See Complete Fee Schedule)— 2 0 0 3200 ill structure 4 not intended or,offered for sale (Section 7044, 6usfheas and Profession Code). 3 2 O O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a constructlon Ipnding agency 0 7.3,1 _8;1 for the performance of the work for which this permit is PERM17 FEE .(Sub-Total) issued(Sec. 3097,Civ.C.). Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUFNG 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 I - ordinances and State .laws regulating Electrical.wiring, and hereby authorize representatives of this County to enter upon- the bove-mentioned property for inspection p ores. SEE REVERSE FOR EXPLANATORY LANGUAGE ,7 3 Lyl Signature of Permittee Data Ie WO i CE-BO6G (2-80)RS'COMPENSA)IONDECLJrARATION APPLICATION FOR ELECTRICAL PERMIT k E�08 I hereby affirm that I have ■ certificate of consent to self COUNTY OF LOS ANGELES WILDING AND SAFETY insu e, or ■ certificate of Workers'Compensation Insurance,or �� e ■ Xfiyed copyh Lr-( c.3800,Lab.C.) 1Q- gmJ"�" . FOR APPLICANT TO FILL IN - JOB G"309 t ' '� Policy No. Company EACH. NO. FEE ADDRESS Z50tZ1 'xWulg New Residential Bldgs.&Pools Certified copy Is hereby furnished. 1 &2-Famlly,Sq. Ft: $ — i LOCALITY �TEF°L.CE G t Multi-femlly Sq. Ft. HrCestlfied copy is file n VT 'Residential Swimming Pobls CROSS ST dap ment. f OWNER OR -0AV ��*)�b 1 FIRM NAME ` Date Applies Outlets: RecLight Sw. MAIL -PIrit 20 ADD RES-Sre + CERTIFICATE OF EXEpiItTION FROM WORKERS' Total No.J�— Addltlonal CITY l cT�1�� G I No. 8 —� COMPENSATION INSURANCE PLAN CHECK ('Phis section need not be completed if the work hm&ed 6Q APPLICANT ndred Lighting Fixtures First 20 ADpRESS 5p A�L.C�S� • by the permit L for one h❑ dollars (3100) or leis.) Additional � ��' � Total No.� O 1 certify that In the performance of the work for which this Flxed Appliances Not Over 1 HP CITY 1 _ R-jr\� Tel No. permit is Laued, I shall not employ any person In any manner PERMIT Lu so.as to become subject to the Workers'Compensation Laws. Renge_Z Haeter_�D,W. CANT V % Oven _Dryer_W.M._ ADDRESS Z Date Applicant Top FAU _W.H. Hood ��an _Other-- CITY Tel No. Exemption,ICETyou APPLICANT: : If, after making bub�ect to Certificate Workersf Dlsp- ✓ Room Air Cond� RE NUMBER �1 4�+� Clss� Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE ED BY dtamed rmevl fCewith such provisions or this permit shall be Size&Type HP,KW, KVA,or KVA 4 Up to 1 Wcl. FINAL r LICENSED CONTRACTORS R DECLAATION T Over 1 to 1 O Incl.Over 1Q to 60 DATE VALI CIATION 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.Busl- BY Crver 100 nags and Professions.Code, and my license L in full force and effect. Services - 1-{l g � 1—0-200 Amp. Under 800 V Llce ` Lic.Cissa Ql)♦1.06-�5 201-1000 Amp. Under 800 V Z7// Contractor Data Over 1000 Amp.or Over 800 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole&AppurtenenFes 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, $usl- Additional Sign Branch Circuits nags and Professions Code): t 3.4 7.O A Misc.Conduits&Conductors 0 I, as owner of the property, will do the work and the Other (See Complete Fee SchedLle)— # e 010 ' 0 2 atruCture L not Intended or offered for sale (Section U. 7044, Business and Professions Code); 1' CONSTRUCTION LENDING AGENCY I hereby affirm that there L a const�uctlon lending agency .may / o'0 0 O O is for the performance of the,work fo which this permit L PERMIT FEE (Sub-Total) ti 4 1' ,issued(Sec.3097,91$,C„�, �� -�ElN 1-C N �, 1 219-80 Lender's Name �3"� s"�+ PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Ada. G~ s 1 PERMIT ISSUING FEE I certify that I have road this application and state that the TOTAL FEE Q above Information Is correct.I agree to comply with all County ordinances and State laws regulating- Electrical wiring, and hereby authorise representatives of this County to enter upo the a" pu�[�.• A SEE'REVERSE FOR EXPLANATORY LANGUAGE � 2 L� �� d lure of Permittee Date