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HomeMy Public PortalAbout9810 HOWLAND DR_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT hereby affirm that have a certif cote of co Asli;v tc 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.) o Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS Q /D Q (� Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ❑ Certified copy is filed with the county building inspec- 1 8 2-Family, Sq. Ft. $ — $ LOCALITY `9 tion department. Multi-family Sq. Ft. — 'NEAREST Residential Swimming Pools CROSS ST. 90 L 0,61Y IZ)657- Date Applicant OWNER OR C FIRM NAME -J CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecsiaLight X Sw.JV -� MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by —� First io r the permit is for one hundred dollars ($100) or less.) Total No.✓c CITY Tel. No. Additional !j '7 d 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 became subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS �x / ,( Total No.� Additional � pP s'!! A• -R" CITY Tel. No. ate A licaft �-�- �' � Fixed Appliances Not Over i HP PERMIT NOTICE n, APPLICANTd If, offer 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. Hood Fan _ Other— LICENSED CONTRACTORS DECLARATION LICENSE OR M I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY and Professions Code, and my license is in full force and effect. CIL Power Apparatus 8 Large Appliances Size 8 Type HP, KW, KVA, or KVAR !✓✓� _ O License Number Lic. Class Up to 1 Incl. t.! FINAL (�/� (J Over 1 to 10 Incl. DATE _( 'Q VALIDATION O Contractor Date❑ Over 10 to 50 Incl. FINAL am exempt under Sec. Over 50 to 100 Inc. BY d B.BP.C. for this reason Over 100 W Date: Services, Swbd., MCC 8 Panelboards `� ► 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 =5 8'3.7 A I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Low for the following reason (Section 7031.5, Business and g # 2 Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors .2 ° ° 8,1.5 0 to(See Complete Fee Schedule)_ structure is not intended or offered for sale (Section Other ° ° ° 81.5 0 7044, Business and Professions Code). ► r CONSTRUCTION LENDING AGENCY ,( 0,0 7-8 3 1 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 GT 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 laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the L.aybo ve-mention e d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date -WORKER'S COMPENSATION DECLARATION 2"019DPW 5,69 76A663 APPLICATION FOR ELECTRICAL PERMIT fiA683 I hereby affirm that I have a certificate of consent lo'self insure, .ors certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JApOOB RE55 (f L Certified copy is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE ❑ ` _ $ - LOCALITY Certified copy is filed with the county building inspection 8i--Family,Sq.Ft. department. Multi-family Sq.FL CNRoss SEARESTr. Date Applicant Residential Swimming Pools ASSESSOR �v ''�AT1 MAP BOOK PAGE © PARCEL DO CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.KO Light S. � FOIBMNAMe COMPENSATION INSURANCE First 20 3 (This section need not be completed if the work Involved by the t, A" Q v� permit is for one hundred dollars($100)or less.) Total No. 35 Additional AODRE !1 I certify that in the performance of the work for which this permit CITY Tel.No. 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 APPLICANTK Total No Additional ADDRESS Dale Applicant 15 OR 20A,120V BRANCH CIRCUITS NOTICE TO APPLICANT: If, after making this Certificate of CITY TeI.No. Exemption, you should become subject to the Workers' Compensation 1 TO 10 INCLUSIVE EACH provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACHPERMIT provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH APPLICANT E LICENSED CONTRACTORS DECLARATION ADDRESS (L d I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH (commencing with Section 7000) of Division 3 of the Business and CITY TeI.No. 0 Professions Code, and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR Q Power Apparatus 8 Large Appliances REG.NUMBER Class. O License Number Lic.Class Size 8 Type HP,KW,KVA,or KVAR DISTRICT No. PROCESSED yBYO��. H Up to 3 Incl , (/ !J /s' W Contractor Date Over 3 to 10 Incl INAL a. DATE (1)Over 10 to 50 Incl. n y ❑ I am exempt under Sec. Over 50 to 100 Incl. g' ` r/ VALIDATION 100 FINAL 8.8P.C.for this reason Over BY Services,Swbd.,MCC 8 Panelboartls V 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 Pale 8 Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law for the fallowing reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ' Code): VM I, as owner of the property,will do the work and the structure Misc.Conduits 8 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 issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ.C.) - PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 5�76 Lender's Address 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 County to enter upon the above-mentioned proper, f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE & 14� UNATURE OFAPPLICANT OR ADENT TE