The URL can be used to link to this page

Home My Public Portal About5823 KAUFFMAN AVE_Electrical__ -`"WORKERS'COMPENSATION DECLARATION 76A663 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 n BlIILDIN AND AFETY e ora certified copy thereof (Sec. 3800, Lab C ) l:r Policy No Company FOR APPLICANT TO-FILL IN y JOB ^�j Certified copy is hereby furnished New Residential Bldgs. 8 Pools EACH 1 NO FEE ADDRESS b X71 1 & 2-Family, S . Ft. $ _ $ LOCALITY LAY Certified copy is filed with the county building inspec- q• tion d part ent- Multi-family Sq. Ft. 'NEAREST � Residential Swimming Pools CROSS ST Date Applicant �`�"�(nf OWNER OR M FIRM NAME CE TIFICATE OF EXEMPTION VROM W RKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE. ADDRESS (This section need not be completed If the work Involved'by First CITY the permit is for one hundred dollars ($100)or less.) Total No. Additional• I certify that in the performance of the'wPLAN CHECK ork 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 I HP PERMIT NOTICE TO APPLICANT. If; after making this Certificate of APPLICANT (,Q, 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 ADDRES with comply with. such provisions or this permit shall be Top _ FAU —W H deemed revoked V 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 1 Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCES BY and Professions Code,and my.license is in fuH'force and effect Power Apparatus & Large Appliances 6, /J Size &Type HP, KW, KVA, or KVAR (� Q License Numb /7v7Lic Class Up to 1 Incl FINAL V 99 Over 1 to 10 Incl DATE VAL11ION 0 Contractor Over 10 to 50 Incl 0 ❑ FINW"14,11,101 U I am xemlundSec Over 50 to 100 Inc. BY W B &P.0 for this reason Over 100 H Services, Sv'bd., MCC& Panelboards' ✓C ► Date. JA Ar, 0 -200 Amp. Under 600 V ' Signature 201 - 1000 Amp Under 600 V ElExemption 1000 Amp.,or Over 600 V Exemption for Reg Maint. Elect SINGLE FAMILY Temp Power Pole&Appurtenonces HOME OWNER-BUILDER DECLARATION Sign-with One Branch Circuit 1 - 0 40.50' " I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits S Law for the following reason (Section 7031.5, Business and cr Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits 8 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) O (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 NQ, above information is correct I agree to comply with all County ordinances and State jaws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon ) the ove-mentioned property for inspection purpo es - SEE REVERSE FOR EXPLANATORY LANGUAGE, Si nature cf Per rttee Llb to WORKERS'COMPENSATION DECLARATION 76-663 to/at APPLICATION- pTION FOR ELECTRICAL PERMIT I hereby affirm'that I hav4a•certifiGate of consent'to.self Insure, CE-806G /� /a! or a certificate-of Workers' Compensation Insurance, or a certified' COUNTY OF LOS ANGELES' BUILDING AND SAFETY copy thereof(Sec 3806,Lab. C) 4 Policy NO ` •' Company FOR APPLICANT TO ^1 FILL IN JOB'- ,+ -_ ' 44 .,. ADDRESS �'/L ❑ Certified copy.Is hereby furnished New Residential Bldgs & Pools EACH NO FEE ; ❑ Certified 6op' $ — $ LOCALITY 7 ti C py Is,''filed'wdh the' county'building'inspection 1,& 2-Fa nily;,Sq Ft r, department:r•' Multi-family Sq.Ft; — NEAREST -7 �l I+ CROSS ST •L�k S,\ '•� Date, Applicant e., Residential Swimming Pools OWNER OR /' �� • -w, FIRM NAME�� _ !'CERTIFICATE OF EXEMPTION'FROM WORKERS' ,Outlets Rec'� Lights Sw. : } MAIL T. COMPENSATION INSURANCE ADDRESS• - �� _ �• First,20' (This sectionrneed,hot be completed if;the work Involved by the t CITY -- �'� Tel,No Total No Additional 77r,, permit.is for one.hundied dollars($100)•or less.) �-°;, - -, •'`' ,I certifythat ih the er_formance of-the work'for�which'this permit PLAN CHECK P e APPLICANT is.Issued; I shall'not employ any person in,any manner so as to bcome subject,to-the.Workers' Lighting Fixtures, Firsf20 ' ADDRESS' „.b Additional , Total No � CITY` Tel No Date, „Applica ;':.'•:, ,', Fixed�•Appliances Not Over"1 HPPERMIT NOTICE TO APPLICANT -If, 'after making .this Certificate of �.' Exemption,you should become subject.to'the Workers'Compensation Range_.Heater_ APPLICANT _•;provisions•of the Labor.Code,-you;must*forthwith comply with such Oven _ Dryer _ W.M`_ ADDRESS 'Provisions'or this permit'shall be deemed revoked. '• Top FAU '-_ WH•— �L A ,`r,;•.LICENSED-CONTRACTORS DECLARATION-- ' ?' CITY Hood Fan �_ Other_ I hereby affirm„that f am licensed under'provisions'of-Chapter 9 Dlsp .Room Air -LICENSE LICENSE OR Class'/ (commencing,with�Sectior 7000) of Dlvision;3,of the Business and REG NUMBER ��' Professions'Code,and my license is in full force and effect. Power Apparatus& Large-Appliances DISTRICT PR _ ED BY V . Li 0 '. _ �b 'Slze:& Type HP,KW,KVA, or KVAR � `� Q , Llcen _ Llc Class G1 Up'to 1 Incl FINAL V [f �Q Over 1 to 10 Incl DATE, Contracto Date �' r ., +116) at VALIDATION,.' Q Over'10 to 50 Incl , U FINAL ❑: I am exempt under Sec' Over 50 to 100 Inc BY W Over 100. n' B&P.C.for this reasonZ Services,Swbd,MCC& Paneltioardsi Date 0- 200 Amp.Under 600 V, ,. Signature _20.1 - 1000 Amp Under 600 V - + Over 1000 Amp or Over 600 V 4❑ '.Exemption for Reg.Maint.Elect. -``• ` ” SINGLE FAMILY .Temp.Power Pole& Appurtenances' 2 t' HOME OWNER-BUILDERDECLARATION Sign with One Branch Circuitw,+ a I hereby affirm that I am exempt from the Contractor's License-Law A C•To� for the,following reason.(Section 7031.5,Business and Professions Additional Sign Branch�Clrcuits' Code) 30e6lI Mlsc 'Conduits & Conductors ❑' 1 ITEMS I,as owner,of the property,will do the work and the structure 1 GI i _ Is not intended or,offered for sale (Section 7044, Business, Other(See,Complete Fee Schedule) _ TOTAL 30 and Professions Code) 3 CONSTRUCTION.LENDING AGENCY :-:CHECK- '"GHEGK"'- 30.60 I hereby affirm that there is a construction lending agency for the. - r performance of,the work for which this permit Is issued(Sec,3097, ,'PERMIT FEE " ; (Sub-Total) ;• , i ' ' ) GHAI�GE Civ c PLAN CHECKING FEE r 7 Lender's Name 5p0 _ PERMIT ISSUING FEE- _15 r 9 °4' i V 10:53' Lender's Address I certify'that I have read this application and'state that•the above •, TOTAL FEE. 3 6 ; Information Is correct. I agree to comply with all County ordinances, aws•regulating Electrical wiring, and-hereby authorize "i• representatFvbS of t C y o e er upon the above-mentioned pXopecty-€e spectio p oses. " 2 Q SEE,REVERSEFOR EXPLANATORY*LANGUAGE Signature of Perml Date