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HomeMy Public PortalAbout5742 KAUFFMAN AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 6A663 DPW 3/87 7APPLICATION FOR ELECTRICAL PERMIT O I hereby a}firm that I have a certificate of consent to self CE 806G msure, oc:a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or eY,ertifaed copy thereof (Sec. 3800, Lab. ) _ Policy Nn,.'a Company ��" FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ,- I7�(l(Certified copy is filed with the county b 'Iding ins ec- 1 & 2-Family, Sq. Ft. $ $ LOCALITY"' ' ^'tion department. Multi-family Sq. Ft. NEAREST CROSS Residential Swimming Pools OWN RSOT.R Dat.g'��r, e? Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS First 20 (This section need not be completed if the work involved by Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) 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 become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION 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. LICENSED CONTRACTORS DECLARATION LICENSENUMBER OR Class. I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. P SED BY > and Professions Code,and my license is in full force and effect. Size&Type HP, KW, KVA, or KVARCP License Number,-"I ,�Li�c. Class_L�.S/ Up to 1 Incl. FINAL V r '�-�a pate Over 1 to 10 Incl. DATE 1 1 VALIDATION 0 Contracto � Over 10 to 50 Incl. FNAL / '[ I-_ F-1 am exempt under Sec. I Over 50 to 100 Inc. g / U LL1 B.&P.C. for this reason Over 100 a Services, Swbd., MCC & Panelboards , Z U) 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 HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): ; ❑ Misc. Conduits&Conductors i "i s F•• tee I, as.owner of the property, will do the work and the structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— _ Business and Professions Code). , E l;i 1=1L m I'' 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) '-•I")f'N C etli.s (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name _'j,_;;j__1j)_)`I PERMIT ISSUING FEE 3 OO Lender's Address I certify that I have read this application and state that the TOTAL FEE 3 3 -av _ f i of } above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby author' a representatives of this County to enter upon bove- ntioned pr perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ` /�✓ // ©s Signature of Permittee Date WORKERS'COMPENSATION DECLARATION 6A66eoaw3ie7 APPLICATION FOR ELECTRICAL PERMIT O W I F!ereby pf4irm that I have a certificate of consent to self 7CE 806G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a�certifiied 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 ❑Certified co is filed with the count buildinginspec- 1 &2-Famil S Ft. . $ LOCALITY copy Y p y q NEAREST tion department. Multi-family Sq. Ft. — CROSS ST. Residential Swimming Pools Date IC— )?/---Applicant A. OWNER ORFIRMNAME ' `�f r CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 ADDRESS (This section need not be.completed'if the work involved by Total No., Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) 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 Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Co ensation aws. Additional �•� 6_ y J Total No. CITY Tel. No. Date ! AppliCC, - Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certi icate'of APPLICATION - 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 ) e with comply with such provisions or this permit shall be Top — FAU —W.H. — 4a, ii uQ- deemed revoked. Hood — Fan —Other— CITY JTel. N Q 2e LICENSED CONTRACTORS DECLARATION LICENSE OR 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 Power Apparatus& Large Appliances DISTRICT NO. PRO SSED BY >_ and Professions Code,and my license is in full force and effect. C d d � Size 8 Type HF, KW, KVA, or KVAR i G �Ga�-G-al-® Q License Numbeer�rff p� //J�75 Lic. Class Up to 1 Incl. FINAL U Contractor /�/�N elieC� Date �` Over 1 to 10 Incl. DATE 1 ) f-:Q��i � VALIDATION 0 '— Over 10 to 50 Incl. FINAL 6 ( Q 1 ❑ I am exempt under Sec. Over 50 to 100 Inc. gY U B.&P.C. for this reason Over 100 I Wa Services, Swbd., MCC& Panelboards ZZ 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 HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Sig •^• a � Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits `-`- Professions Code): ^Clfiµ;= ❑.I, as owner of theproperty, will do the work and the Misc..Conduits& Conductors -•}.H: t ^: structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Professions Code). ' �f"Al CONSTRUCTION LENDING AGENCY I i• ylYj -.•. 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) Q i_)�'jf'i�'GE (Sec. 3097, Civ. C.). PLAN CHECKING FEE (� Lender's Name i r{''S' -f 4 .3 PERMIT ISSUING FEE 'g, -• Lender's Address �^d� 1 ;T°,.,,.. 1 certify that I have read this application and state that the TOTAL FEE AN ::1_r above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize represent ives of is County to.enter upon Athee-mention d pro rty for ' spection purposes9./ SEE REVERSE FOR EXPLANATORY LANGUAGE oTPermittee Date