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HomeMy Public PortalAbout10311 KEY WEST ST_Electrical__ WORKERS' COMPENSATION DECLARATION 76A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT •I hereby affirm that I have a certificate of consent to self ce sobs insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS oa�r a certified copy thereof (Sec. 3800, Lab. .) Pdl1 ryL0o7�1�-6 � tJ y o. ompany f FOR APPLICANT TO FILL IN JOB 1 ❑ �`Certified copy is hereby furnished. /-1 New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 03! 1 7s . WCertified copy is filed with the county iiding in ec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY e L� CYi on department. 14 Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. Date Applicant OWNER OR FIRM NAME CE TIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec—.Light Sw. MAIL W S COMPENSATION INSURANCE First 20 ADDRESS (This section need not be completed if the work involved by Total No. 5 Additional CITY em u C el. NoIJ I 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'Compensation Laws. Additional Total No. 'Z CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATIO Cj L 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. CITYTel. No. Hood — Fan —Other LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. — Room Air Cond. _ REG. NUMBER Q Class. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY >_ and Professions Code,and my license is in full force and effect. a- {� Size &Type HP, KW, KVA, or KVAR / "w Q License Number —0 0Q q n Lic. Class_t2 Up to 1 Incl. FINAL U 11`1C(�l.1ry��, �, O Over 1 to 10 Incl. DATE " VALIDATION cc Contractor Date Over 10 to 50 Incl. I— ❑ FINAL U I am exempt under Sec. Over 50 to 100 Inc. 4BY W B.&P.C. for this reason Over 100 /, a Services, Swbd., MCC& Panelboards , f Z Date: 0-200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect, Over 1000 Amp, or Over 600 V SINGLE FAMILY Temp. Power Pole &Appurtenances y s � HOME OWNER-BUILDER DECLARATION ACCT.r _{ 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 3307 14.40 Professions Code): 1 ITEKS ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ TOTAL- Business and Professions Code). , CHECK 1i�etiCl CONSTRUCTION LENDING.AGENCY CHANGE pllEl Ihereby 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 0000_0001 s/ 21/(1 Lender's Name 3 �� 874.3 1 AM10.,A1 PERMIT ISSUING FEE Lender's Address j 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 hereby authorize representatives of this County to enter upon the above-mentioned property fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE An gnature of Permit ee Dat ©s WORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT 1 he{e.by affirm CE-806 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 Pol Certified copy is hereby furnished. New Residential Bldgs. & Poo „�j EACH NO. FEE ADDRESS 1 & 2-Family, S Ft. of $ — $ LOCALITY �ertified copy is filed with the county building inspec- Y, q tion department. Multi-family Sq. Ft. NEAREST � �A/jGCROSS ST. ` 6r�� �� Residential Swimming Pools OWNER OR p �x Date v Applicant�R�'— v� FIRM NAME 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. "' CITY Tel. No. the permit is for one hundred dollars ($100)or less.) Additidnal`� 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 G�G NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT G*�>P-N �21%'G 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 8225' U with comply with such provisions or this permit shall be Top FAU —W.H. — deemed revoked. CITY - (A Tel. No. -7 Hood _ Fan _Other_ LICENSED CONTRACTORS DECLARATION LICENSE OR / I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER 3Z`5`0fo Class.�j(G1' >= (commencing with Section 7000) of Division 3 of the Business ppDISTRICT N PRO CE BY d' Power Apparatus & Large Appliances and Professions Code,and my license is in full force and effect. L � U 32�O t3 Jr Size &Type HP, KW, KVA, or KVAR' l7 c-� License Number Lic. Class i Up to 1 Incl. 4FINAL vb !O �Q� Over 1 to 10 Incl. � ' V ATIONContractor ate1'3 Over 10 to 50 Incl.❑ I qm exempt under Sec. Over 50 to 100 Inc.Over 100 NB.&P.C. for this reason 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 ;2327.9A HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # 0 0 0 0 0 '2 6 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): ' o - 8650 El1, 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)_ , o ­ 86506 7044, Business and Professions Code). CONSTRUCTION LENDING AGENCY I Q24-85 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 Lender's Name /I PERMIT ISSUING FEE Cl 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 hereby authorize representatives of this County to enter upon thea ve-mAtied property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si natur of Permittee Date