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HomeMy Public PortalAbout9842 KEY WEST ST_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806G 10181 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have o certificate of consent to self �� insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES t BUILDING AND SAFETY or a certified copy thereof (Sec 3800, Lab C ) Policy No Company FOR APPLICANT TO FILL IN JOB 9 Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS 4 7/1 ❑ 1 & 2-Family, S Ft $ — $ LOCALITY C ~ Certified copy is filed with the county building mspec- Y 9 tion department Multi-family Sci Ft — NEAREST Residential Swimming Pools CROSS ST Date Applicant OWNERO FIRM NAM CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light Sw_ MAIL COMPENSATION INSURANCE ADDRESS This section need not be completed if the work Involved b First 20 ( p y Total No CITY Tel No the permit is for one hundred dollars ($100)or less ) Additional that in the erformance'of the work for which this PLAN CHE I certify P APPLICANT permit is issued, I shall not employ any person in any manner so as to become sublet}to the Worker 'Compensation aws Lighting Fixtures First 20 ADDRESS J r "al.No Additional CITY Tel No Date Applicant ix d Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT If, after making this ertificate 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 —JLW H deemed revoked CITY Tel -No LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ Disp Room Air Cond LICENSE Class I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER (commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO PRO C BY >_ and Professions Code,and my license is in full force and effect tL Size & Type HP, KW, KVA, or KVAR O License Number Lic Class Up to 1 Incl FINAL V Over 1 to 10 Incl DATE C� g VALIDATION 0 Contractor Date Over 10 to 50 Incl C� u ❑ FINAL 1 am exempt under Sec r Over-50 to 100 Inc BY d B &P C for this reason Over 100 r h Date Services, Swbd , MCC & Panelboards z 0 9 a 4 A z 0 -200 Amp Under 600 V l# o,0 0 0 0 2 Signature 201 - 1000 Amp Under 600 V t Over 1000 Amp or Over 600 V 2!0.014 0 0 Exemption for Reg Mamt Elect _ SINGLE FAMILY Temp Power Pole &Appurtenances 0,0 to "Y 0 0 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 0 4 0 5—8 3 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) ❑ 1, as owner of the property, will do the work and the Misc Coriduits& Conductors structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , 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 Lender's Name PERMIT ISSUING FEE C`! Sfl Lender's Address I certify that I have read this application and state that the TOTAL FEE O above information is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring, and ereby authorize representatives of this C ty to enter upon e ab a-me toned p perty for insp ti purpo es SEE REVERSE FOR EXPLANATORY LANGUAGE r4nature of Permittee Date / WORKERS'COMPENSATION DECLARATION CE 806G (2-80) 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 a certified copy thereof(Sec 3800, Lab C) FOR APPLICANT TO FILL IN JOB 642 1 e}/ QS Policy No Company ADDRESS New Residential Bldgs &Pools EACH NO FEE Certified copy is hereby furnished 1 &2-Family,Sq Ft $ — $ LOCALITY .ems Multi-family Sq Ft NEAREST Certified copy is filed with the county building inspection CROSS ST H Q department Residential Swimming Pools OWNER OR FIRM NAME 11041 Date Applicant Outlets Rec/_0 Sw _j" AIL ' 15421.'e/� First 20 ADDRESS ` CERTIFICATE OF EXEMPTION FROM WORKERS' Total No1— Additional P COMPENSATION INSURANCE J.Z" CITY ` Tel No2 �,r� y,i PLAN CHE J I CL O (This section need not be completed if the work involvedAPPLICANT U by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First o ADDRESS Total No Additional O 1 certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No F" permit is issued, I shall not employ any person in any manner t` ��'✓ PERMIT W so as to become subject to he Workers' Compensation Laws Range_ Heat D W APPLICANT d Oven _ Drye�W M _ ADDRESS Cn Date`_ A App] Top — FAU —W'�I Z [� Hood _ Fan _OtherCITYel No NOTICE TO APPLICANT If, after making this Certificate of Disp _ Room Air Cond_ w_ V LICENSE OR Exemption, you should ecome-subject to the Workers' REG NUMBER Class Compensation provisions f the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO ME with comply with such provisions or this permit shall be deemed revoked Size&Type HP,KW, KVA, KVAR ©� Up to 1 Iricl ',• 90 Over 1 to 10 Incl& FINAL DATE _ VALIDATION , LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl "`� i 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 licenseis in full'force and effect Services License Number Lic Class 0-200 Amp Under V 201-1000 Amp Under 600 V Contractor 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 ;21 4 3 8 A ness and Professions Code) Misc Conduits& Conductors #'0'0r0 0 0 2 I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 2 i,° 4 1,3 structure is not intended or offered for sale (Section 7044, Business and Professions Code) _ CONSTRUCTION LENDING AGENCY 1Q 4 1.7J Q v I hereby affirm that there is a construction lending agency 1 0_06.-81 for the performance of the work fog which this permit is PERMIT FEE (Sub-Total) issued (Sec 3097,Civ C) Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING 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 bov ment ned erty for inspe ion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date