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HomeMy Public PortalAbout4815 HALLOWELL AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 10ie1 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 ❑ Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS f ' �� ❑ 1 & 2-Famil S Ft. $ — $ LOCALITY L� Certified copy is filed with the county building inspec- Y� q tion department. Multi-family Sq. Ft. — NEAREST CROSS ST. Residential Swimming Pools OWNER OR Date Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec'f J Light Sw. MAIL COMPENSATION INSURANCE ADDRESS This section neenot completed if the work involved b i First ( tid t b p Y Total No. Additional20 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 Total No. Additional CITY Tel. No. Date 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. CITY Tel. No. LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_ Disp. _ Room Air Cond. LICENSE OR Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY a and Professions Code, and my license is in full force and effect. Power Apparatus 8 Large Appliances O Size & Type HP, KW, KVA, or KVAR V License Number Lic. ClassUp to 1 Incl. FINAL / / W DATE / Over I to 10 Incl. �G ' VALIDATION Contractor Date 50 10 t Over o Ind. ElFINAL < I am exempt under Sec. Over 50 to 100 Inc. BY Q this reason Over 100 - / � B.&P.C. for h s easo O Services, Swbd., MCC& Ponelboards , Date: 0 - 200 Amp. Under 600 V d Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Mainz. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits • a + • " Law for the following reason (Section 7031.5, Business and Professions Code): y- I, 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)_ , • o 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.). r 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 lows 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 Permittee Date WORKERS'COMPENSATION DECLARATION C-663 10/81 APPLICATION FOR ELECTRICAL E ECTR�C/il p PERMIT I hereby affirm that I have a certificate of consent to self insure, CE-806G i�'� 6i F! 1V fl L 1 fl /1L r fl�V� or a certificate ofNWorkers' Compensation, Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab. C.) Policy No.lA3�... 3�&FCo mpany FOR APPLICANT TO FILL IN JOB �t S .� 1 ❑ Certified copy is hereby furnished. t New Residential Bldgs.& Pools EACH NO. FEE ADDRESS ❑ Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. f $ _ $ 1LOCALITY department. rr�� Multi-family Sq.Ft. LAV NEAREST CROSS ST. Date 11 O Applicant lV esidential Swimming Pools OWNER OR A! FIRM NAME m/`\ W CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light _ Sw. MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the First 20 CITY Tel.No. permit is for one hundred dollars($100) or less.) Total No. Additional 1 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 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 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of (✓WSW Exemption,you should become subject to the Workers'Compensation Range_- Heater_ D.W. _ APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS 3 S 2' k provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY u Tel.No. $ '� -- I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. LICENSE R f 4T-) e (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 PROC SED B �) t Size& Type HP, KW,KVA,or KVAR i® O License Number``'' 4�p Lic.Class C © Up to 1 Incl. LNA V i � •d(JL�+- 3 p t Over 1 to 10 Incl. VALIDATION C) Contractor ll �t^�`^�` ate 9 Over 10 to 50 Incl. ❑ I am exempt under Sec. Over 50 to 100 Inc. W Over 100 �- B.&P.C.for this reason Cn 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 ED . Exemption for Reg.Maint.Elect. 11 0 SINGLE FAMILY Temp.Power Pole& Appurtenances V V s a HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCT.4 I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits 3307 i� = for the following reason(Section 7031.5, Business and Professions Code): " " I ITEMS ❑ Misc. Conduits & Conductors _ I,as owner of the property,will do the work and the structure '��O is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t �- -9-`'� and Professions Code). CHECK® I CONSTRUCTION LENDING AGENCY CHANGE 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 Lender's Name ' 1 AM 9:13= PERMIT ISSUING FEE '^"�7'f`' 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 property for inspection pur oses. rl SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee "� Date