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Home My Public Portal About5758 KAUFFMAN AVE_Electrical__ It WORKER&COMPENSATION DECLARATION' 76A663 f 1;/81 APPLICATION ,FOR:+ELECTR'ICAL PERMIT I•'hereby affirm that I have a certificaCE-806G ate of consent to self Insure, 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 ADDRESS 57679lL� EACH, NO _ FEE Certified copy is hereby furnished. New Residential Bldgs &'Pools LOCALITY Certified'copy Is•filed.with the county budding Inspection 1 & 2-Family,Sq.'Ft $ department' Multi-family Sq.Ft. — NEAREST - _ CROSS ST- d i'•/C�atit.^ �J , Date Applicant Residential Swimming Pools w OWNER OR �. .� _ - _ • FIRM NAME, �. /'reAl--7--JiV . CERTIFICATE OF EXEMPTION.FROM WORKERS',• ' Outlets Rec .Light Sw. •': �ADDRESS.`' COMPENSATION INSURANCE f l This•section need,not be com tfie,. First,20 Tel ' ( pleted y ' Total No Additional CITY X61�� . - No permit is for one hundred.,dollars($1if-the work in'vol'ved b00)or less.) . ionai; - PLAN CHECK I certify that in the performance of the work,for which this permiti ApPLCANT, LUN is.issued,'I.shall not employ, any person in any.manner so as'to become subject to the Workers'Comp anon Laws- Lighting Fixtures First'20•' ADDRESS•• + ° Additional O , Total No - CITY - - Tel.No Date O Applicant -Fixed Appllances.Not Over 1 HP" PERMIT' NOTICE TO •APPLICANT' If, after mak, t Certi is of APPLICANT Exemption,.you should become subfect to,the Wor ers'Compensation Range_ Heater_ DW _ provisions of.the Labor-Code, you must`forthwith comply with such. Oven Dryer W M ADDRESS provisions or This'pe�md shall be deemed revoked Top —•FAU WH CITY 'F Tel No. ` LICENSED CONTRACTORS DECLARATION Hood Fan Other_ I hereby affirm.,that I am 'kensed.under provisions,pf,Chapter 9 Other— LICENSE OR- (commencing with Section 7000) of-Division 3 of the Business and ;Disp — Room Air Cond Class. REG NUMBER Professions Code;and'my license is in full force and effect':" Power A DISTRICT NO' PROCESSED Apparatus& Large Appliances ^ - Size& Type,HP,KW,I<VA,or KVAR 'License Number Lic Class 'Up.to 1 Incl." FINALS Over Itto10 Incl. fJAT `._ti - P VA LIDA 4 Contractor Date °Over* 10 to 50 Incl. FINA 0 I am exempt under Sec. Over 50 to 100 Inc BY , LU B&PC for this reason '• - Over 100 Services, Swbd,MCC& Panelboaf _ Date 0- 200 Amp Under 600 V v rI Signature 201 - 1000 Amp Under.600 V l' Over 1000 Amp'or Over 600-V -.612 550 Exemption for,Reg Maint Elect. 2 5'S Q r SINGLE FAMILY Temp Temp Power Pole& Appurtenances HOME,OWNER-BUILDER DECLARATION • ' 'Q O 4 t 8 8 Sign with,One Branch Cu'cud• - • - - 1 hereby-affirm that I am exempt'from the Contractor's License Law l-Sign Branch,Circuits . - for the following reason (Section Additiona ,7031 5, Business and Professions " � ` �• � - - -• - • Code)' I,as owner of the property,will do the work and the structure M,sc'Conduits & Conductors , .. ,s not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) _ and Professions Code).. + r CONSTRUCTION'LENDING AGENCY o e I hereby affirm that there ,s a construction lending agency for the•, performance of the work for which this permit,s Issued(Sec 3097, -PERMIT-FEE (Sub-Total) ; y., `- '• ' Civ C .,* _PLAN CHECKING FEE r' - Lender's Name - PERMIT ISSUING FEE' t, Lender's Address ' I certify that-I have read this application and state that the above TOTAL FEE x ,nformafion,,s correct I agree to comply with"all County ordinances _ and State laws regulating Electrical wiring, and hereby authorize , repres ntatrves of this County,to enter upon the above-mentioned - .prop t for,nspectio rppses SEE REVERSE FOR EXPLANATORY LANGUAGE„ ignature f Peofnittee Date �; `�„ WORKERS' COMPENSATION DECLARATION '76A663 DPwaie7 APPLICATI®N FOR ELECTRICAL PERMIT O �J 76A663 I he7e6y affirm that I' have a certificate of consent to self cE-806G' Insure, or a certificate of.Workers' Compensation-Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS ora celtified copy thereof (Sec. 3800, Lab C. Policy No.—, Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs 8 Pools EACH NO FEE ADDRESS ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq- Ft. $ _ $ LOCALITY tion department Multi-family Sq Ft NEAREST / j, i CROSS ST yV�14 3' -`--SA,1 Residential Swimming Pools' , Date Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM•WORKERS' . - Outlets Rec LightSw MAIL ,` J COMPENSATION INSURANCE ADDRESS 77 W. . First 20 (This section need not be completed Wthe work involved by Total No. Additional CITY �' �j Tel."No."�� the permit is for one hundred dollars ($100)or less.) PLAN CHECK I'cerfify that'in the performance of the work for which thisuJ�l�)y PPLICANT 'permit is issued, I shall not employ any person in any manner so`as to become subject to the-Workmers' opensatio ws. Li9h tal Fixtures First 20 ADDRESS ' � � Additional Date Applicant Total No.� CITY Tel No . Fixed Appliances Not Over 1 HP PERMIT NOTICEAO APPLICANT. If, after making thi ertificat o APPLICATION i' Exemption, you should become subject to the Workers' Range— Heater—D W. ' Compensation provisions of We 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. LICENSED CONTRACTORS'DECLARATION Hood Room —Other Disp. Room Air Cond LICENSE OR I hereby affirm that I am licensed urider provisions of Chapter 9 REG NUMBER Class (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO -PROCY >- and Professions Code,and my license is in full force and effect. /�� d Size &Type HP, KW, KVA, or KVAR CV O License Number Lie. Class Up to 1 Incl. FINAL, U Over 1 to 10 Incl. DATE VALIDATION 0 Contractor - Date 0 Over 10 to 50 Incl. FINA� I am exempt under Sec Over-50 to 100 Incgy 0 B &P C for this reason Over 100 / d Services, Swbd., MCC& Panelboards 4 Date: Z 0- 200 Amp Under 600 V - Signature 201 - 1000 Amp: Under 600 V Over 1000 Amp: or Over 600 V T a Exemption for Re Maint Eject 1 p g �063,6•A SINGLE FAMILY L HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances } • # o.• • e •,2 I hereby,affirm that.l am exempt from the Contractor's License Sign with One.Branch Circuit J Low for the following reason (Section 7031 5, Business and Additional Sign Branch Circuits 3 �.� �,. ) ''e • 1 275 Pro essions Code): ,e • m,1 2 7 5 j„as owner of the property, will do the work and .the Misc Conduits 8 Conductors structure is n6t intended or offered for sale(Section 7044, Other.(See Complete Fee Schedule)— 0 9, 0 91-8 8 Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is o'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 v 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 her y authorize representatives,of this County to enter upon t bove-mentione property for inspectionpur oses SEE REVERSE FOR EXPLANATORY LANGUAGE Os ^Signatur of ermittee Date