The URL can be used to link to this page

Home My Public Portal About4816 HALLOWELL AVE_Electrical__ WORIC,ERS'COMPENSATION DECLARATION -663 10/81 APPLICATION FOR ELECTRICAL PERMIT {� �I'here"y>�a�(irm thatCE I have a certificate of consent to self insure, CE-806G �J csr a cehiflcate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3$AO,Lab. C.) Policy No.—, Company FOR APPLICANT TO FILL IN JOB r, ❑ 6 p Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS ❑ 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. NEAREST CROSS ST. A _ Date Applicant Residential Swimming Pools OWNER OR i- -FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL COMPENSATION INSURANCE Outlets:Rec Light Sw. ADDRESS (This section need,not be completed if the work involved by the Tel.No. First 20. Total No. Additional CITY—� C i permit is for one hundred dollars ($100) or less.) ` PLAN CHECK I certify that in the performance of the work for which this permit 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 Total No. , Additional CITY �� Tel.No.c.��(`y� Date �4'� ELpplicant ��""' t Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT ) S provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. _ ADDRESS provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. CITY _ Tel.No i1Y43. 5 -LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter9 Disp. — Room Air Cond. LICENSE OR Class. (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. _ f(VG PROC SED < Q�' Size & Type HP, KW,KVA, or KVAR Number Lic.ClassINAL 0 License Up to 1 Inc].Incl. Over 1 to 10 Incl. DATE — Contractor Date FINAL U VALIDATION ConO ❑ Over 10 to 50 Incl. I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 Z Services,Swbd.,MCC&Panelboards Date: O-200 Amp.Under 600 V 8.0 7.4 A Signature 201 - 1000 Amp.Under 600 V ❑ Over 1000 Amp. or Over 600 V # 0000,02 Exemption for Reg.Maint.Elect. I -,o,1 4,25 SINGLE FAMILY Temp.Power Pole & Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit o o.'0 1 (J 2 5,5 1 hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): �1 Q O 7�8 7 li ❑ I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) 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' d(Sec.3097, PERMIT FEE (Sub-Total) Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEEfAh (J Lender's,Address e I certify that I have read this application and state that the above TOTAL FEE J information is correct. I agree to comply with all County ordinances and State laws regulating trical wiring, and hereby authorize representatives of thislC unty to enter upon the above-mentioned roperty for inspeeti rf' urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE v /r� X2-7 Signature of P mit ee Date tNORKERS'COMPENSATION DECLARATION 76- 10/81 CE-806806G APPLICATION FOR ELECTRICAL PERMIT �~ -� •-• I hereby; affirm.that I have a certificate of consent;to•self insure, or a Itertificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS 4 40 A4/ Certified copy is filed with the county building inspection 61 2-Family, Sq.Ft. /�C�� $ _ $ LOCALITY I/"1 department Multi-family Sq.Ft. NEAREST /� Date 1 .3 CROSS ST. LUZvy (,rj• Applicant �� Residential Swimming Pools OWNER OR CE TIFICATE OF EXEMPTION FROM WORKERS' 2t h FIRM NAME Outlets:Rec- Light t 2 MAIL COMPENSATION INSURANCE •• 15 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 _ 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 to become ject,to the Workers'Compen�n awst Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel.No. Date / Applicant Fixed Appliances Not Over. 1 HP PERMIT NOTICE TCf APPLICANT: If, after making tfis Certificate of Exemption,you should become subject to the Workers'Compensation Range_ Heater t'D.W. APPLICANT provisions.of the Labor Code, you must forthwith comply with such Oven Dryer / W.M. �� ADDRESS provisions or this permit shall be deemed revoked. Top FAU W.H.LICENSED CONTRACTORS DECLARATION Hood Fan Other CITY Tel.No. I hereby affirm that I am licensed under provisions of Chapter 9 / LICENSE OR Disp. oom Air Cond. REG.NUMBER Class. (commencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect. DISTRIC N PROC ED B Power Apparatus& Large Appliances Size& Type HP, KW, KVA, or KVAR (/X O License Number Lic.Class Up to 1 Incl. FINAL Q Over 1 to 10 Incl. DATE ��. VALIDATION Q Cractor Date Over 10 to 50 Incl. U FINAL I am exempt under Sec. Over 50 to 100 Inc. BY � B.&P.C_for this reason Over 100 N Services,Swbd.,MCC& Panelboards ® Z / Date: Q,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 a I hereby affirm that I am exempt from the Contractor's License Law a B for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits ACCT Code): • n5U Misc.Conduits& Conduct ors 3307 _7.0 I,as owner of the property,will do the work and the structure. 1 ITEMS is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) and Professions Code). ® TOTAL 70.50 0 CONSTRUCTION LENDING AGENCY CHECK 70.50 1 hereby affirm that there is a construction lending agency for the �t n performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHARGE 500 Civ.C.). PLAN CHECKING FEE Lender's Name 0000-0001 10/30/89 PERMIT ISSUING FEE V Lender's Address 6439 1 ASI 8:21 1 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 Count to ter upon the above,-menti ned pXw- gignature n p p SEE REVERSE FOR EXPLANATORY LANGUAGE of Per (lnr( pfate WORKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT I h--y 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. Compony4 FOR APPLICANT TO FILL IN JOB 11O , Qll Certified copy is hereby furnished.` � New Residential Bldgs. & Pools EACH NO. FEE ADDRESS U `7 Ci Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY NEAREST tion department. Multi-family Sq. Ft. �y rJ Residential Swimming Pools CROSS ST. Date Applicant FOWNER OR IRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 ADDRESS 9LG e l 4Y3�f(This section need not be completed if the work involved by Total No. CITY Tel. No. the permit is For one hundred dollars ($100)or less.) Additional 7 I certifythat in the performance of the work for which this PLAN CHECK P erAPPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Worker 'C pens n L Lighting Fixtures First 20 ADDRESS —,S>,/' Total No. Additional CITY Tel. No. 41 Date Applicant Fixed Appliances Not Over 1 HP PERMIT r 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 OR �+ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER 3 77 �� Class.(� (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PRO D BY 0- Power Apparatus & Large Appliances and Professions Code, and my license is in full force and effect. �j U //'' ))� Size &Type HP, KW, KVA, or KVAR' ✓l License Number 77�� Lic. Classes Up to 1 Incl. DATE L Over 1 to 10 Incl. V IDATION O Contracl9p 9W Date Over 10 to 50 Incl. FINA f am exempt under Sec. Over 50 to 100 Inc. B.&P.C. for this reason Over 100 - Z Date: Services, Swbd., MCC& Panelboords g ► 0 -200 Amp. Under 600 V go I 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 #�4 3'�0 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 °'O 2550 Law for the following reason (Section 7031.5, Business and Professions Code): o o 0 Misc. Conduits&Conductors 2 5 0 v 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 4 02 a 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) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name { PERMIT ISSUING FEE 10 Lender's Address I certify that I have read this application and state that the TOTAL FEE �S�SWl 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 boned perty fo spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 5ignat,7re of Permi tee Date