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Home My Public Portal About10400 KEY WEST ST_Electrical__ WORKERS'COMPENSATIONDECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT �oTa15- CE 806G (2-80) I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES �.� BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or T r 1 a certified copy thereof(Sec 3800,Lab C) FOR APPLICANT TO FILL IN JOB Policy No Company EACH NO FEE ADDRESS F1 New Residential Bldgs &Pools Certified copy is hereby furnished 1 &2-Family,Sq Ft M y V $.02 — $ LOCALITY L Multi-family Sq Ft — NEAREST Certified copy is filed with the county building inspection CROSS ST Residential Swimming Pools department FO RM NR OR AME Date Applicant Outlets Rec Light_ SW MAIL First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY` Tel No COMPENSATION INSURANCE } PLAN CHECK it (This section need not be completed if the work involved APPLICANT by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 , ADDRESS U Total No Additional I certify that in the performance of the work for which this Fixed Appliances Not Over 1'HP CITY Tel No 0 permit is issued, I shall not employ any person in any manner PERMIT so as to become subject to the Workers' Compensation Laws Range_ Heater_D W APPLICANT �i� �/ JO�� o W Oven _ Dryer_W M ADDRESS ^' S rF 0- ,tqZ Datefr7 lrl�"Applicant Top FAU _W H CITY �?'� O Tel No �� Hood _ Fan _Other_ NOTICE TO APPLICANT If, after making this Certifica Disp _ Room Air Cond._ LICENSE OR _ Exemption, you should become subject to the Workers' REG NUMBE Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO PROCE ED BY with comply with such provisions or this permit shall be Size&Type HP, KW, KVA,or KVAR deemed revoked Up to 1 Incl FINAL Over 1 to 10 Incl DATE LICENSED CONTRACTORS DECLARATION � . /� �/ VALIDATION Over 10 to 50 Incl I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL- BY INAL-BY 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 ness and Professions Code, and my license is in full force and effect Services ) G�� 0-200 Amp Under 600 V License Number-3a �� Lic Class 'Q 201-1000 Amp Under 600 V Contractor Date O Over 1000 Amp or Over 600 V • ' HOME OWNER-BUILDER DECLARATION Temp Power Pole&Appurtenanbes I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031 5, Busi- Additional Sign Branch Circuits ness and Professions Code) Misc Conduits& Conductors ;1 79.8 A st as owner of the property, will do the work and the Other (See Complete Fee Schedule)— structuTe is not intended or offered for sale (Section # o�0 0 0 0 2 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY 2 o,,o Q 8 1' O I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub-Total) !� _ o o�o 4 a 1 �� issued (Sec 3097,Civ C) Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 11,02-81 Lender's Address PERMIT ISSUING FEE 7 I certify that I have read this application and state that the TOTAL FEE 4-f g- )6 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 for inspection purposes SEE REVERSE-FOR EXPLANATORY LANGUAGE Signature of Permittee Date „ WORKERS'COMPENSATION DECLARATION .D ICE 806G 12-80) - APPLICATION FOR ,ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY �. insure, or a certificate of Workers'Compensation Insurance,or �Isolicnlo_AX� c3800,Lab C) G�� FOR APPL'ICAN�T TO FILL IN JOB _\11�-� EATHN FEE pany - , er— ew Residential Bldgs &PoolsADDRESS Certified copy is hereby furnished Ill &2-Family,Sq Ft $E $ L0CALITI AREST Certified copy is filed with the coun uilding inspection Multi-family Sq Ft CROSS ST' IlyeResidential Swimming Pools OWNER OR FIRM NAME Tn Datpplica Outlets Rec_Light Sw MAIL First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY Tel N COMPENSATION INSURANCE } PLAN CHECK d APPLICANT (This section need not be completed if the work Involved � Additional by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First ADDRESS cc Total No 0 I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tet-Na permit is issued, I shall not employ any person-in any manner PERMIT 0 so as to become subject'to the Workers' C mpensation Laws Range_ Heater_D W _ ' APPLICA W 01/� Oven Dryer_W M _ ADDRESS 11-3 z Da( , nt f`--t�1,(`lY, Top _ FAU _W H Hood Fan _Other_ CITY T NOTICE TO APPLICANT If, after making this Certificate of Disp _ Room Air Cond._ t LICENSE OR Exemption, you should become subject to the Workers' RNUMBE EG R lass Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO PROCESSED BY with comply with such provisions or this permit shall be deemed revoked Size&Type HP,KW, KVA,or KVAR Up to 1 Incl oy Over 1 to 10 Incl DATE L LICENSED CONTRACTORS DECLARATION �_/�—�� VALIDATION Over 10 to 50 Incl I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc BY AL 9 (commencing with Section 7000) of Division 3 of the Bush Over 100 ness and Professions Code, and my license is in full force and effect ) Services License Nu ber is C ss �^-� 0-200 Amp Under 600 V 201-1 000Amp Under 600 V Contrac Date Over 1000 Amp or Over 600 V HOME OWNER-BUILDER,DECLARATION Temp Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License Law for the following reason (Section 7031 5, Busi- Additional Sign Branch Circuits ness and Professions Code) Z'5 7 2 7 A ' Misc Conduits&Conductors � Y 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— #'0 0,0 0 0 2 structure is not intended or offered for sale (Section , 7044, Business and Professions Code) 2'010 3 5 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency o Yo 0 3 g 5 Q for the performance of the work for which this permit is PERMIT FEE (Sub-Total) . issued (Sec 3097,Civ C) I Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) ' 0 1 9—82 Lender's Address PERMIT ISSUING FEES 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 e abovef, boned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee ate