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Home My Public Portal About9230 LIVE OAK AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 10/81 CE-806 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-806G i6sure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab ) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 1 & 2-Family, S Ft. $ — $ LOCALITY Certifie copy is filed with the county building inspec- . q• — ti de rt ent. Multi-family Sq. Ft. 'NEAREST L.C�'r/ CROSS ST. licant Residential Swimming Pools OWNER OR Da App FIRM NAME 94( CE TIFICATE OF EXEMPTION FROM WORK RS' Outlets: Rec1?1 Light I Sw. MAIL COMPENSATION INSURANCE ADDRESS s section neenot completed if the work involved b First 20 (Thitid t b p Y Total No. Additional CITY Tel. No' 96 the permit is for one hundred dollars ($100)or less.) I certify that in the performance of the work for which this P LAPLICANTK 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.. A I 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. — deemed revoked. Hood _ Fan _Other_ CITY I. No. LICENSED.CONTRACTORS DECLARATION LICENSE O I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NU ER Q z Class (commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROC S BY and Professions Code,and m license is in full force and effect. Power Apparatus & Large Appliances @. Y Size &Type HP, KW, KVA, or KVAR' 0 License Number Lic. Class Up to 1 Incl. FINAL V 09 Over 1 to 10 Incl. DATE /� / '�� VA ATION 0 Contractor ate Over 10 to 50 Incl. FINAL U LU Over I am exempt under ec. Over 50 to 100 Inc. BY � � Over 100 B.&P.C. for this reason Date: Services, Swbd., MCC & Panelboards , 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ElExemption 1000 Amp. or Over 600 V �7 4.1,'9,A Exemption for Reg. Maint. Elect. # o',0 4 0;,b 'Z SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit .1 :° 1 4,25 1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits x Law for the following reason (Section 7031.5, Business and g ° °•O 1 IL 2 5.0 Professions Code): El1, as owner of the property, will do the work and the Misc. Conduits& Conductors Q 7,07-87 structureis 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 /O 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 thea ve-mentioned pr perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date V:• ...!ER'S COMPENSATION DECLARATION 76A669 DPW(i2-9t) APPLICATION FOR ELECTRICAL PERIVIIT ,� 76A663 I herEby aYf li'4n that I have a certificate of consent to self insure, or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec. 3800 La C.) Policy N ompany r5n 0 FOR APPLICANT TO FILL IN JOB r ADDRESS I/ Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE — $ $ LOCALITY Certified copy is filed wit county din insp o 1 &2-Family,Sq.Ft. NEAREST ^ ' departmen. Multi-family Sq.Ft. CROSS ST. G Date Applic t Residential Swimming Pools ASSESSOR PAGE PARCEL CERTIFICATE OF EX MPTIO FROM WORKERS' Outlets:Rec._Light Sw. OWNER N R' COMPENVTION SURANCE First 20 AIL I (This section need not be c if the work involved by the ADDRES Apermit is for one hundred d00)or less.) Total No. Additional J I certify that in the performance of the work for which this permit CI Tel.No. _qfbq is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such PER�AAPPLI T n� provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances LICENSED CONTRACTORS DECLARATION Size&Ty e HP,KW,KVA,or KVAR DDRE 'r` I hereby affirm that I am licensed under provisions of Chapter 9 er 3 to 10 Incl. =. (commencing with Section 7000) of Division 3 of the Business and Tel.Nor<r� Professions Code, and my license is in full force and effect. �� Over 10 to 50 Incl. SE R'+ } .Over 50 t0 100 Incl RIEGNNU BER � Class .+Z Over 100 DISTRICT NO. ESSED BY 0 License Number Li n Services,Swbdd.,MCC&P elboar If 0ldrlr nU43 FINAL Contract a DATE ❑ I am xempt under Sec. 400-1000 Amp.Under 600 V / VALIDATION W Over 1000 Amp.or Over 600 V FINAL d .&P.C.for this reason BRANCH CIRCUIT FEES BY / Date: 15A,or 20A, 120V,Lighting or Recept. / Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ _ 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits j a... SINGLE FAMILY Temp.Power Pole&Appurtenances _ s HOME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): [ s I ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 5 5 3 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). CONSTRUCTION LENDING AGENCY v i-IANG- I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) Civ. C.) S :) `s—_I; PLAN CHECKING FEE - " Lender's Name j O f j'_ PERMIT ISSUING FEE (p Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE that the above information is correct. I agree to comply with all County ordinances and laws egulatin Electrical wiring and hereby authorize representative of is C unty to ter pon th - tione prop rty Ins do p ose . M _ J SEE REVERSE FOR EXPLANATORY LANGUAGE p os /(� SIGN URE PERMITTEE DAT