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Home My Public Portal About6262 IVAR AVE_Electrical__ WORKERS'OOMPENSATION DECLARATION •�'I rt ereby ' u -603 10181.. CE-806G affirm that I have a certificate of'consent.•to self insure, APPUCAMONFOR 2E CTwAL PERMIT _, or a certificate of Workers' Compensation Insurance, or a certifiedBUILDING COUNTY'OF,LOS ANGELES 'AND SAFETY py' ( r'..o thereof Sec. 3800,Lab.C.) Policy No. 'Company_ FOR APP i Certified copy:,is hereby furnished New.'Residential Bldgs.&Pods.' ANT TO'FILL IN, .: JOB, ,..►-.. la • . EACH NO. FEE' ADDRESS Certified copy is filed with•the county budding'inspection 1 &'2-Family,Sq.Ft ' department', r Multi-family Sq.Ft. $ - $ :LOC ALITY pp NEAREST C�� ,� nt Swimming PoolsY; �q 1 CROSS ST. • Reside ial OWNEROR Date A licant . . , FIRM NAME CERTIFICATEOF EXEMPTrON f ROM WORKERS'.' Outlets:Rec tight MAIL' — Sw COMPENSATION INSURANCE, .• -+.• ADDRESS Y, This`section,need,not be completed if the work involved.b the First 20 ( p Y CITY„: TeI:No. permit is,for oneohundred dollars($100)-or'.less) Total No: Additional PLAN CHE K I jcertify'that in.the performance of the work-for.which this.,permit APPLICANT J§ issued, I shall.not employ any person in any manger so as to become subject to the;Workers'Compe tion Law Lighting Fixtures . '• 'First 20 ADDRESS Additional, Total No:- CITY, el No. Date i I APPlican .. .. l Fixed'Appliances Not Over 1 HP PERMIT NOTICE- TO, APPLICANT If;., of e 'making ;tlis Certificate- of - - ;Exemption,.you should become subject.to theMprkers'Compensation Range_,Heater_,D.W: .APPLICANT' provisions of.thelabor Code,you,must forthwith comply'with such Oven'— Dryer — W.M._ ;ADDRESS provisions or'this permit shall be deemed revoked.. Top FAU' W.H. Vj - LICENSED-CONTRACTORS DECLARATION Hood —'Fan". Other_ I;,hereby.affirm,that.d am licensed under provisions of Chapter 9 LICENSE O Disp.'— Room Air"Cond. ?CITY . o. Class. Tel.N (commencing with Section 7000):of Division 3 ofr.the Business and " Professions Code,and my license is in full force and effect.' Power Apparatus Large Appliances F; I R/��{ • REG NUMB _ . "' DISTRICT N ^� PROCESSED_BY Size& Type HP,'KW.KVA,or KVA.R '� L License Number Lid.Class O' Over 1.to 10 Incl. , FINAL DATE ` Contractor DateOver 10 VALID TION O 0, 50 I am.exempt under Sec: Over 50 to,10.0 y b B.&P C for this reason Over 100CL Services .Swbd MCC&Panelboards . 200 Amp.Under 600.V Signature .' 201 -.1000"Amp. Under 600 V " ❑ Over.1000 Amp.or Over 600 V. Exemption for Reg Maint Elect. SING"' FAMILY Temp Power,Pole&'Appurtenances . Q +2 A . 8 HOME OWNER-BUILDEf :DECLARATION ::f hereby:'affirm-that I am exempt from':the-Contractor's`License'Ldw Sign with One Branch Circuit #.0.0 0 0 0•2 for,tHe followin� reason (Section 7031:5, Business and,Professions Additional Sign Brandi Circuits g Co ). ', I 2 S 5°0. �L.is Misc Conduits'& ConductorsI,.as owner:of the property,will do the work and-the structure'., 0 00.2 5 not intended or'offered for sale (Section 7044; Business Other(See Complete Fee Schedule) D and,'Professions Code). '02 0 8--8 8 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 Cki.C.). .. (Sub-Total) PLAWCHECKING 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 ,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 pro rty.for iansnpurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE i aWre of Date • e affirm KERS'COMPENSATION DECLARATION CE-806 10/81 APPU A N FOR EL1�C��UC� °,d PERMlV N t-hereby affirm Jhat 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 co s hereby furnished. EACH NO. FEE ADDRESS 1;Z� �\/ � PY Y New Residential Bldgs. & Pools ❑ 1 & 2-Family, S Ft. $ _ $ LOCALITY Certified copy is filed with the county building inspe_c, Y. 4� tion department. Multi-family S4. NEAREST CROSS ST. (�iti(6-�C Residential Swimming ing Pools OWNER OR Date Applicant FIRM NAME ��G. 4U rZ/ AlC. Z,5 U CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light• Sw. MAIL _ / COMPENSATION INSURANCE �' ADDRESS �Z 6 Z iZ �. (This section need not be completed if the work involved by First 20 Total No. Additional V CITY m�'� � Tel. No.2 the permit is for one hundred dollars_($100)or less.) I certify.that in the of the work for which this PLAN CHECK e performance APPLICANT permit is issued, I shall not employany person in any manner so as to become subject to the Wo rs'CoPat, Laws. Lighting Fixtures First 20 ADDRESS Additional T No. CITY o. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, afte m king this rtificate of APPLICANT UV JExemption, you should become subject to the Workers' Range_ Heater_D.Wt — 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. CTORS DECLARATION LICENSE OR LICENSED CONTRA I hereby affirm that I am licensed under provisions of Chopter 9 . Disp. — Room Air Cond. 0 REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCESS BY and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT d Size & Type HP, KW, KVA, or KVAR' O License Number Lic. Class Up to 1'Incl. W FINAL _ U Over 1 to 10 Incl DATE �_` V ATIOPd Q Contractor Date Over 10 to 50 Incl. _ U FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY -�� . z 2 b 9 b A a B.&P.C. for this reason Over 100 to Services, Swbd., MCC & Ponelboords '�it D # o o 0 0 0 2 _Z Date: 0 200 Amp. Under 600 VYJ (fIV Signature 201 - 1000 Amp..Under 600 V. )1t ❑ I Over 1000 Amp. or Over 600 V 1J o - 3 (100 Exemptio for Reg. Maint. Ele t. �J r� p j .( SINGLE FAMILY Temp.-Power Pole& Appurtenances }L�1�� c o o 3(10 0 5 / i HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 1� a 1 (l _a 5 I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5; Business and Professions Code): }, ❑ Jv}�Q(D I, as owner of the property, will do the work and the Misc. Conduits&Conducto'r's structure is-not intended or offered for sale (Section Other (See Complete Fee Schedule)_ D \� 7044, Business and Professions Code). �P} 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 v '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 reby authorize resentatives of this County to enter upon t e above-menti Id pr erty for inspection rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE a Date _ �r� KERS' COMPENSATION DECLARATION 76-663 10/81 A Pj p �,p�AMON 2®R E ECTM A PERNT Z/P hEt)y,affirm that I have a certificate of consent to self insure, CE-806G Ill�v I�L� l� III Ir Lt-r �o LL or a certificate 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. EACH NO. FEE ADDRESS New Residential.Bldgs.&Pooh ❑ -`` _ $ LOCALITY $ ' ] /�✓v Certified copy is, filed with the county,building .inspection �G 1 & 2-Family,Sq.Ft. department. /• Multi-family Sq.Ft. NEAREST CROSS ST. Residential Swimming Pools OWNER OR Date -Applicant _ ",.FIRM NAME //"fZ(C ��U iL, SO!<! CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec 3i2 Light Sw. 'j, MAIL COMPENSATION INSURANCE / ADDRESS jtlCyf 1/%/M (This section need not be completed if the work involved by the, Q�� First 20 permit is for'one hundred dollars($100)or less.) Total No._LCL Additional, CITY L �� Tel,No. �� y , I certify that iri the performance of the work for which this permit PLAN CHECK _ �t APPLICANT is issued; I shall,not 'employ any person in any manner so as to become subject to the Workers'Compen tion Laws Lighting Fixtures First 20 ADDRESS p Total No. �- Additional �✓ CITY Tel.No. Date, Applicant Fixed Appliances Not Over 1 HP PERMIT 4 'NOTICE 'TO APPLICANT;'",If, •after making this •Certificate of, APPLICANT. ' Exemption,you should become subject to the Workers'Compensation Range Heater D.W. L ,provisions of the Labor Code,'you must forthwith comply with such Overt Dryer.? W.M. �. ADDRESS provisions or this permit shall be deemed revoked: Top fAU w.H. LICENSED CONTRACTORS DECLARATION CITY Hood Fan OtherTel.No.- _ 1''hereby affirm that I'am'licensed under provisions of Chapter 9 LICENSE OR bisp; Room Air Cond. 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. DISTRICT NO. ,.� PROCESSED BY . .Power Apparatus& Large Appliances � ( y'� O ' Size& Type'HP,KW,KVA, o or KVAR License Number Lic.bais's Up to 1 Incl. FINAL U Over 1 to .10 Incl. DATE <'r AION Contractor Date V/1 O Over o 50 Incl. H FINAL ❑ I am exempt under Seo, Over 50 to 100 Inc.- BY ti W CL BAP.C.for this reason Over 100 Services,Swbd.,MCC& Pane Dater lboards )r(.�` / ' Z 0- 200 Amp.,Under 600 V D {`! S-"h ✓ , ��!" Signature. 201 - 1000 Amp.Under 600 V 9 9 4 A Over 1000 Amp:' or Over 600 V ❑ Exemption for Reg.MainL,Elect. # 0,0 o.oro SINGLE FAMILY Temp. Power-Pole& Appurtenances �-o 767 HOME OWNER-BUILDER DECLARATION ` Sign with One Branch Circuit e 0,6 7(j,7 4 05 I hereby affirm that I am exempt from the Contractor's License taw _ for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits 47: Other 04, 02 -88 Misc.Conduits& ConductorsI,as owner.of the property,will do the work and the structure is not intended or,offered for sale (Section 7044, Business (See Complete Fee Schedule) _. and Professions Code). D CONSTRUCTION LENDING AGENCY ) 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 PERMIT ISSUING FEE U L'ender'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 i and State laws regulating Electrical wiring, and hereby authorize repr ntatives of thi County to enter upon the above-mentioned o y for insp on urpos s. u SEE REVERSE FOR EXPLANATORY LANGUAGE �igrEfure of Per ittee' Date