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HomeMy Public PortalAbout4840 HELEO AVE_Electrical__ WORKERS'COMPENSAicate o consent.to 76-663 10/81 APPLICATION FOR ELECTRIC- PERMIT h` y'afifirf�,-Kiat I tiav�'a,pe'rtificate of consent.to self insure, CE-806G APPLICATION �o leo LC, IIMII or a certificate of VYorkers' 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 - � ❑ Certifled.copy is hereby furnished. New Residential Bldgs.&Pools EACH . NO. FEE.. ADDRESS' (/ Certified copy, is filed with the;county building inspection 1 & 2-Family,Sq.Ft. $ — $ LOCALITY L dep tmen: Multi-family Sq.Ft. — NEAREST CROSS ST. 1 . %,�// Residential Swimming Pools _ OWNER O Date /! �� Applicant�CE kGr�� � 5 _ FIRM NAM E. L'.E�� 'CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL Outlets:Rec Light SW COMPENSATION INSURANCE— ADDRESS (This section need not be completed if the work involved by the First 20 CITY Tel.tJo. C` permit,is for one hundred dollars($100).or less.) Total No. Additional 0 7 7� +,certY if •that,in the performance of,the work for which this permit PLAN CHECK APPLICANT- CLGE. / is.�issued,1 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 NOTICE'•�TO APPLICANT, If; after making this -Certificate of PERMIT Exemption;you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT provisiorls,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. LICENSED CONTRACTORS DECLARATION Hood Fan Other- 1-.hereby ther_1 hereby affirm that I am licensed under. provisions of Chapter 9 Disp. Room Air Cond. LICENSE OR / (commencing-with Section 7000) of Division 3 of the Business and REG.NUMBER �p ClasS: 'Pr ofessiohs Code,and rriy'license is in full force and effect.' DISTRICT NO. PROCE E By . Power Apparatus& Large.Appliances ..,� Size& Type HP,'KW,KVA,'.or KVAR License Number �� �� Lic.Class 'Up to 1.Incl. FINAL" y� 0 ���ff� //�y�� Over 1 to 10 Incl. DATE �j �CJ� V IDATION Contractor LLI�r?��-� `�"��Date �/ 0 ~ r Over 10 to 50 Incl. FIN- V I am exempt under Sec. Over,50 to 100 Inc: B n W 0- . .,. B:&P:C.for this reason Over 100 4826 eJ A N Services,.Swbd.;MCC &Panelboards Z Date: 0-200 Amp.Under 600.V. , •# o,o'0:0.0 2 Signature 201 - 1.000 Amp.Under 600 V Over 1000 Amp:oi`Over 600 V - ❑ Exemption for Reg. Maint.Elect. I ,o SINGLE FAMILY• -Temp.Power-Pole&.Appurtenances e'o d'37.5 0 5, HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby-affirm that I am exempt from the Contractor's License Lawd for the following reason(Section 7031.5, Business and Professions ;Additional Sign Branch Circuits '1.,0 3&8,.7 Code): Misc:Conduits'&Conductors ❑., I,as owner of.the property,.will'do the work and the structure is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ and Professions Code). D" '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•(Sec.3097, P.ERMIT:FEE (Sub-Total) Civ. C.). PLAN CHECKING,FEE Lender's Name PERMIT ISSUING FEE _.. Lender's Address I.certify that•I'have read this application and state that the above` TOTAL FEE �f�� 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 i pection purposes. SEE.REVERSE FOR EXPLANATORY LANGUAGE. - Signature of Permittee ate L+, WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPU a,gMON F®� ELEC p-�"�ICA ry�ERNT • Ihhereby affirm that I have a certificate of consent to self insure, CE-806G �sdW YF'1 �e II �o L� IT IMI or oce,tificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY ccfiY thereof (Sec. 3800,Lab.C.) Poligy No. Company FOR APPLICANT TO FILL IN JOB Q ❑ EACH NO. FEE ADDRESS J IYeG/ Certified copy is hereby furnished. New Residential Bldgs.& Pool ❑ Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ = $ LOCALITY department. Multi-family Sq.Ft. .NEAREST CROSS ST. Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Reck Light -Sw. MAIL COMPENSATION INSURANCEADDRESS C This section need not be completed if the work involved b the First 20 ( pY Total No. Additional p`Z CITY Tel.No. permit is for one hundred dollars($100)or less.) I certifythat in the performance of the work for which this permit PLAN CHECK p 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 0 © ADDRESS TAdditional Total No. CITY Tel.No. Date Applicant NOTICE TO APPLICANT: If, after makingthis Certificate of Fixed Appliance Not Over 1 HP PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. O APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESSWE provisions or this permit shall be deemed revoked. Top FAU W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan OtherCITY Tel.No. _ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR (commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond: REG.NUMBER Class. Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. SSED ev Size& Type HP,KW,KVA,or KVAR 0 License Number Lic.Class Up to 1 Incl FINAL r Over 1 to 10 Incl. DATE 'Y- 0 /� -VALIDATION Contractor Date Over 10 to 50 Incl. CO~) ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. W 01Over 100 n- B.&P.C.for this reason N Services,Swbd.,MCC& Panelboards D �. Date: 0- 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 ,.. I hereby affirm that I am exempt from the Contractor's License Law }(A for the following reason (Section 7031.5,Business and Professions Additional Sign Branch Circuits -, i Code): r- 7= _ TT f_ ❑ Misc.Conduits& Conductors �•y-y I,as owner of the property,will do the work and the structure 1 1 i'.{1C is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ 70 and Professions Code). {{_t Irwd 3 a CONSTRUCTION LENDING AGENCY t Ii •r: 44.710 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) 0 CHANGE' Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE D Lender's Address � - I certify that I have read this application and state that the above TOTAL FEE 0 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 ecti purpos s. _ SEE REVERSE FOR EXPLANATORY LANGUAGE Q& Sign ture of P r ittee gate 11