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Home My Public Portal About6017 KAUFFMAN AVE_Electrical__ 4 �� 'WORKERS'COMPENSATION DECLARATION 76A663 1081 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 Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS El Certified & 2-Family, S Certified copy is filed with the county building inspec- q. Ft. LOCALITY $ — $ tion department. Multi-family Sq. Ft. — NEAREST CROSS ST. Residential Swimming Pools OWNER OR Date Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Re��Light�Sw.7 0 r AMAIL DDRESS COMPENSATION INSURANCE Tis section neenot completed if the work involved b First 20 ( hid t b p Y Total No. Additional j CITY �� 7e1. N�7 the permit is for one hundred dollars ($100)or less.) I certifythat in the performance of the work for which this PLAN CHECK P erAPPLICANT permit is issued, I shall not employ an son in any nn so as to become subject to the Wor omp tLighting Fixtures First 20 ADDRESS Additional r( Total No. -- CITY Tel. No. Date ._ �l/C�Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certi r,cote 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. — CITY y Tel. N deemed revoked. Hood Fan _ Other— LICENSED CONTRACTORS DECLARATION LICENSE OR //.l a I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER , M Class. G (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCE BY and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances CL C Size &Type HP, KW, KVA, or KVAR' I U/1 License Number -3 2-L��Lic. Class Up to 1 Incl. FINAL ! V Contract U�C/Y Icc �^ Over 1 to 10 Incl. DATE VAAATICIN Date Over 10 to 50 Incl. FINAL U I am exempt under Sec. Over 50 to 100 Inc. BY LLI B.&P.C. for this reason Over 100 Date: Service's, Swbd., MCC& Ponelboards 0. t!f O)L 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 &Appurtenances HOME OWNER-BUILDER DECLARATION 7 1,3 A Sign with One Branch Circuit # o o o o o 2 I hereby affirm that Im aexempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and r - 3 3 550 Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits & Conductors o o 03 a 5 Q'r=� structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► 320-85 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) (Sec. 3097, Civ. C.). PLAN CHECKING FEE D O 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 ordinanc s and State laws r gulating Electrical wiring, and here thorize repr se ve f this County to enter upon the ve-menti pr rt r in cti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS' 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 Certified co s hereby furnished. EACH NO. FEE ADDRESS d ✓ PY Y New Residential Bldgs. & Pools — Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft $ LOCALITY — $ Eli tion department. Multi-family Sq. Ft. NEAREST Residential Swimming Pools CROSS ST. Date Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' I MAIL COMPENSATION INSURANCE Outlets: Rec Light Sw._ s ADDRESS _ r _ First 20 (This section need not be completed if the work involved by Total No. CITY Tel. No. the permit is for one hundred dollars ($100)or less.) Additional (i I certify that in the performance of the ork for which this PLA LCANTK permit is issued, I shall not employ an r n y manner S �. so as to become subject to the War ation,L s. Lighting Fixtures First 20 ADDRESS �� Total No. R Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP / NOTICE TO APPLICANT: If, aft r making t -is ertificate of pp APPLICANT / T' 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. Hood — Fan _Other_ CIT Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. _ Room Air Cond.. — REG. NUMBERZ�a Class. I hereby affirm that I am licensed under provisions of Chapter 9 �— (commencing with Section 7000) of Division•3 of the Business DISTRICT NO. PROCES D BY and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances /� 9L Size &Type HP, KW, KVA, or KVAR' S- v d License NumA6�Lic. Class,c_/6 Up to•1 Inel. FINAL �� Over 1 to 10 Incl. DATE _ VALIDATION Contracto Date Over 10 to 50 Incl. �+ FINAL V ❑ y I am exempt under Sec. Over 50 to 100 Inc. BY c l �,� LU B.&P.C. for this reason Over 100 Services, Swbd., MCC & Panelboards / ► jn� d�j Date: 0 -200 Amp. Under 600 V / / lJ Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit r I hereby affirm that I am exempt from the Contractor's License 0 6 v A Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): o c o o 2 E-1 MlConduits &Conductors I, as owner of the property, will do the work and the 7 0 0 0,7 5 structure is not intended or offered for sale (Section Oth r ( e Com lete Fee S e d u )� 7044, Business and Professions Code). �,•� ► r c c 4 0 ;cs CONSTRUCTION LENDING AGENCY 0'2'2 — ,4I 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) U (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Ell Lender's Address I certify that I have read this application and state that the TOTAL FEE )1 above information is correct. I agree to comply with all County ordinonand State laws regulating Electrical wiring, and here y thorize represe . ive - this County to enter upon thea-menti p rt y ins ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P tee Date