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Home My Public Portal About10405 KEY WEST ST_Electrical__ -WORKERS'that M,civ TION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT 17 hereby affirm tha I ave a certificate of consent to self CE-806G insure, or, tificaV-,Workers' Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certi ied py t (Sec 38 C ) Policy No am any FOR APPLICANT TO FILL IN JOB Pol Certified copy is h r y rnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS r-1 Certified copy is filed w h e count b spec- 1 & 2-Family, Sq Ft $ — $ LOCALITY NEAREST r d art Multi-family Sq Ft CROSS ST Residential Swimming Pools OWNER OR Dat ��`� Applicant I 1 FIRM NAME CERTIFICATE OF EXEMPTION FRO RKERS' Outlets Rec'�Light Sw_� M {MAIL COMPENSATION INSU E First 20 _ 3 p ADDRESS E (This section need not be completed if t e work involved by,, Total No Additional CITY Tel N 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 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 with comply with such provisions or this permit shall be Top _ FAU —W H — � CITY Tel No deemed revoked Hood Fan _ Other_ LICENSED CONTRACTORS DECLARATION _ Disp Room Air Cond LICENSE �? I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER G.J4el/ Class � (commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO P CE ED BY and Professions Code,and my license is in full for effect (� O ZjQ�j/ Size &Type HP, KW, KVA, or KVAR , 0& V License Number �_ A Lic Class Up to 1 Incl FINAL DAT t % v Over 1 to 10 Incl DATE d v VALIDATION ContracO ❑ �Date Over 10 to 50 Incl FINAL - I am exempt under Sec Over 50 to 100 Inc BY B 8P C for this reason Over 100 Date Services, Swbd , MCC 8 Panelboards 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 8 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 8 Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , 7044, Business and Professions Code) 5 5 a,8 A CONSTRUCTION LENDING AGENCY #;o,0 0 0 0 2 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) 1,- o l 3 50 (Sec 3097, Civ C ) PLAN CHECKING FEE °I' ° 1 3 5 0 5 Lender's Name 6) 0 1.03d786 PERMIT ISSUING FEE ( ' L der's Address I c rtify that I ha a pplication and state That the TOTAL FEE 13, ab informat'a is o gree to comply with all County rdiie.ntes and t gulating Electrical wiring, and h re y authors e p t tives of this County to enter upon th a ove t n a erty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of er tee Date WORKERS'COMPENSATION DECLARATION 63 CE 806G (2-80) APPLICATION FOR ELECTRICAL- PERMIT CE 8 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES -("// BUILDING AND SAFETY insure;ora certificate of Workers'Compensation Insurance,or t a certified copy thereof(Sec 3800,,Lab C) FOR APPLICANT TO FILL IN JOB Policy No Company EACH NO FEE ADDRESS New Residential Bldgs &Pools ❑. Certified copy is hereby furnished 1 &2-Family,Sq Ft /* $ $ LOCALITY -� EJ ; Multi-family Sq Ft — NEAREST- Certified copy is filed with the county building inspection CROSS ST department Residential Swimming Pools L OWNER OR r� J FIRM NAME /C_/ CJ, Datz Applicant Outlets Rec_Light Sw MAIL First 20, ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY Tel No • COMPENSATION INSURANCE PLAN CHECK r a APPLICANT (This section need not be completed if the work involved Lighting Fixtures First 20 by the permit is for one hundred dollars ($100) or less.) Additional ADDRESS CCo I certify that in the performance of the work for which this Total No CITY Tel No 00 Fixed Appliances Not Over 1 HP U 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 ` J' 1 114 E5 S' 1 Co 11"u a '' Oven _ Dryer_1W M ADDRESS 16-60 No Date/_��Applicant �I -.3C!/ Top FAU _W H t� Hood _ Fan _Other_ CITY-01, 7nk9lo Tel No r �� NOTICE TO APPLICANT If, after making this Certificates Disp -Room Air Cond._ LICENSE OR Exemption, you should become subject to the Workers' REG NUMBER Class Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO PRO ES D BY with comply with such provisions or this- permit shall be Size&Type HP,KW, KVA,or KVAR (5/��1a deemed revoked (/� ' Up to 1 Incl FINAL Over 1 to 10 Incl DATE / Z "VALIDATION, LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl v ��✓ I hereby affirm that I-am licensed under provisions of Chapter Over 50 to 100 Inc FINAL 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY ness and Professions Code, and my license is in full force and effect Services License Number Lic Class 0-200 Amp Under 600 V 201-1000 Amp Under 600 V Contractor DateOver 1000 Amp or Over 600 V HOME OWNER-BUILDER DECLARATION Temp Power Pole&Appurtenances § 1 6 2 8 A I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit # o 0- 6 o2 License Law for the .following reason (Section 7031 5, Busi- Additional Sign Branch Circuits ness and Professions Code) - 2'0 5225 Misc Conduits&Conductors — ? 5 2 2:5`5 I, as owner of the property, will do the work and the 0,21 8 1 ❑ Other (See Complete Fee Schedule)— ' structure is, not intended 'or offered, for sale (Section 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 PERMIT FEE (Sub Total) issued (Sec 3097,Civ C) , Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel Lender's Address PERMIT'ISSU4NG FEE 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-menti ned property for ins tion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date