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Home My Public Portal About5710 KAUFFMAN AVE_Electrical__ WCrm that' COMPENSATION DECLARATION CE-806 10/81 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 / D Certified co is hereby furnished. EACH NO. FEE ADDRESS Y copy Y New Residential Bldgs. & Pools 1 & 2-Family, Ft. $ _ $ LOCALITY— El G Certified copy is filed with the county buildin inspec- - q tion department. Multi-family Sq. Ft. NROSS ST.EAREST C 41 /94 Residential Swimming Pools OWNER OR Dote,vo,m,rlApplic FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS s section neenot e completed if the work involved b First 20 (Thiid b p Y CITY Tel. No. the permit is for one hundred dollars ($100)or less.) Total No. Additional that in the performance of the work for which this PLAN CHECK I certify p 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 Additional CITY Tel. No. Total 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. 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 Class. Q ca (commencing with Section 7000) of Division 3 of the Business ppDISTRICT NO. PROC BY pr, Power Apparatus& Large Appliances and Professions Code,and my license is in full force and effect. ! IJP Q �j P� Size &Type HP, KW, KVA, or KVAR' �V/ � vU V License Number- -7 �� Lic. Class �`r"� UP to 1 Incl. FINAL 0. L7i Contractor Date Over 1 to 10 Incl. DATE r ✓Q VALI ATION Over 10 to 50 Incl. FINAL Over 100 W I am exempt under Sec. Over 50 to 100 Inc. BY 7/'- C. for this reason z Date: Services, Swbd., MCC& Panelboords , 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maine. 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 Law for the following reason (Section 7031.5, Business and 4 1 3.4 A Professions Code): Misc. Conduits&Conductors '#.o'o o e o 2 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)— ► c 7044, Business and Professions Code). t' o o 2 5.5 O CONSTRUCTION LENDING AGENCY .® e o Q v z I hereby affirm that there is a construction lending agency for 2 5 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). 228-86 PLAN CHECKING FEE ., Lender's Name On PERMIT ISSUING FEE `0 Lender's Address I certify that I have read this application and state that the TOTAL FEE aS"s 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 Ahev.e.7en"O�nedp�ertyfor inspectio�p �. SEE REVERSE FOR EXPLANATORY LANGUAGE of Pem ti ,�fi, S��COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby,o�firm !hat I have a certificate of consent to self CE-806G insure, tr 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 j p Certified co is hereby furnished. EACH NO. FEE ADDRESS �/ PY Y New Residential Bldgs. 8 I ❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ ERYAL LOCALITY tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. Date Applicant OWNER OR -��y FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Lightw Sw.{d�✓ MAIL COMPENSATION INSURANCE ADDRESS 3 f AJ 0 s section neenot completed if the work involved b First 20 (Thitid t b p Y Total No. Additional CITY t �' G Tel. No. the permit is for one hundred dollars ($100)or less.) that in the performance of the work for which this PLAN CHECK I certify p APPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation L ws. Lighting Fixtures First 20 ADDRESS � Total No. AdditionalCITYTel. No. Date � pplican ' Fixed Appliances Not Over 1 HP PERMIT t„r ` NOTICE TO APPLICANT: If, after making this Certificate RC APPLICANT �� 1 CI Exemption, you should become subject to the Workers Range Heater_D.W. Compensation provisions of the Labor Code, you must forth- Oven Dryer — W.M.— ADDRESS r O t with comply with such provisions or this permit shall be Top FAU —W.H. . deemed revoked. Hood Fan 4-- Other_ CITY Tel. No. LICENSED CONTRACTORS DECLARATION i LICENSE OR Disp "7 Cla . Room Air Cond. REG. NUMBER ss Ihereby affirm that 1 am licensed under provisions of Chapter 9 � (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROC E BY (L Power Apparatus& Large Appliances and Professions Code,and my license is in full force and effect. "'5— U O '� , �y Size$Type HP, KW, KVA, or KVAR C License Number Lic. Class � Up to 1 Incl'. FINAL CIf� r- Za3��(� Over 1 to 10 Incl. DATE VA ATION Contractor� � L=am= Date —(P eb Over 10 to 50 Incl. ❑ FINAL < W' I am exempt under Sec. Over 50 to 100 Inc. BY B.&P.C. for this reason Over 100 U) Services, Swbd., MCC & Panelboards ► Date: 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V 0 4 5 a 4 A ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole& Appurtenances o o o. 05...0 $bb 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 Law for the following reason (Section 7031.5, Business and Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 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) 5 (Sec. 3097, 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 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 above-mentioned proper f r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Per ittee Date