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Home My Public Portal About10306 KEY WEST ST_Electrical__ WORKERS'CO/vtiPENSATION DECLARATION CE 806G 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby.,affirm •that I have a certificate of consent to self 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 OZ ❑ Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ❑ 1 & 2-Fomil S Ft. $ — $ LOCALITY Certified copy is filed with the county building inspec- Y. 9• tion department. Multi-family Sq. Ft. — NEAREST 41 Residential Swimming Pools CROSS ST. Date Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Re, Light Sw._ MAIL COMPENSATION INSURANCE a ADDRESS This section need not be completed if the work involved First 20 ( P b Y . CITY Tel. No. the permit is for one hundred dollars ($100)or less.) Total NoAdditional I certify that in the performance of the work for which this PLAN CHECKAPPLICANT 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 Total No. CITY Tel. No. Date Applicant xed Appliances Not Over 1 HP PERMIT NOTICE TO A PLICANT: If, after making this Certificate of , P L� Exemption, you should become subject to the Worker Range_ Heater_D.W. — APPLICANT 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 CITY Tel. N _ _Other_ 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 DISTRICT NO. P S D BY and Professions Code,and my license is in full force a effect. Power Apparatus& Large Appliances ` d Q . 0 Size &Type HP, KW, KVA, or KVAR License Number, Lic. Class Up to 1 Incl. FINAL Contractor Date Over 1 to 10 Incl. DATE �o VALIDATION Over 10 to 50 Incl. FINA f I— I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 �� N Date: Services, Swbd., MCC& Ponelboards ► 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. ai t. 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 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). 6 0 2 9 A CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for # 0 0 o o o 2 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). I o o 1 350 Lender's Name PLAN CHECKING FEE 1 3,50= PERMIT ISSUING FEE 4® � Lender's Address .1 .1,2 6 8 b I certify that I have read this application and state that the TOTAL FEE 3 , 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 th abov mentioned prop ty or inspection purpos S. SEE REVERSE FOR EXPLANATORY LANGUAGE gnature ofermittee `bate WORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm CE-806 shot 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 1 & 2-Famil ADDRESS ��.T�� • V�� +ei7� V tified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE S — $. LOle tified copy is filed with the county building inspec- Y� q• Ft. $ OCALITY c— tion department Multi-family Sq. Ft. NEAREST c� �!, ^ Residential Swimming Pools CROSS ST. C ASC Date ,� 23 F5 Applicant AAA- f-Ge-c g OWNER OR FIRM NAME ��J�sC) 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 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 per 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 lZ2s ��L �J ¢— with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. CITY l() Tel. No.R k 7 57 54 LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other— LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Z'SOS (0 Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROC SE BY �' and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances Size 8 Type HP, KW, KVA, or WAR License NumbersZdFa�r0 Lic. Class C4'0 Up to 1 Incl. FINAL DATE O .0(A, kL�' /0 3 Over 1 to 10 Incl. VAL ATION Contractor Date ❑ Over 10 to 50 Incl. FIN L' W I am exempt under Sec. Over 50 to 100 Inc. B 1Z' 100 Z B.BP.C. for this reason Over Z_ Date: Services, Swbd., MCC & Ponelboards 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 Temp. Power Pole& Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 3 2 7,7 A 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 # 0 0 0 o a 2 Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits& Conductors I o o 9 Q 5 0 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 7044, Business and Professions Code). ► o o o 9 Q 5 0 v CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for I G24-85 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (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 hereb authorize representatives of this County to enter upon the ove-mention pro e r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE c4 23 g Signatur Of Permittee Date