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Home My Public Portal About5402 LOMA AVE_Electrical__ I - WOCOMPENSATION DECLARATION 10/81 I her?by`affrm that I have.a certificate of consent to self CE-806G APnCU N FOR ELEC CAL PERW7 insure, or a certificate of Workers' Compensation Insurance, i COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certifIed,copy thereof (Sec 3800, Lob C ) Policy No Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS l Certified copy is filed with the county building inspec- 1 & 2-Family, Sq Ft $ — $ LOCALITY tion•deportment Multi-family Sq Ft — NEAREST Residential Swimming Pools CROSS ST Date Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' 1JtL Outlets RecLight�Sw MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by First 20 Total No the permit is for one hundred dollars ($100)or less.) Additional CITY / Tel No I certify that in the performance of the wo k for which this PLAN CHECK APPLICANT permit is issued, I shall not employ any pe n in - manne so a's to become subject to the Workers mpe t n Law Lighting Fixtures First 20 ADDRESS Total No�` Additional Date y Applicant— CITY Tel No 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 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 8 Large Appliances DISTRICT NO PROCES ED BY and Professions Code, and my license is in full force and effect Q Size&Type HP, KW, KVA, or KVARU License Number Lic Class Up to 1 Incl FINALd:Over 1 to 10 Incl DATE � Contractor Date VA ATIOIV L) r-1Over 10 to 50 Incl FINvl/ /� lrl I am exempt under Sec Over 50 to 100 Inc BY B&P C for this reason Over 100 Date Services, Swbd , MCC& Panelboards D 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 2.4 1 3.6 A 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 ;# o•0 0 0 0 2 Law for the following reason (Section 70315, Business and Prof sslons Code) I o a 1 4,50 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)_ o 0 0 1 4,5,0 cZi 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY O 2 2 8,t 8 6 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 U 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 jaws regulating Electrical wiring, and ;tgnature Wermittee atives of this County to enter upon rty for inspection purposes yy/ SEE REVERSE FOR EXPLANATORY LANGUAGE 67--6N Date WORKERS'COMPENSATION DECLARATION 76A663CE-806 io/8t APPLICATION PP ICATION I! OR EILIG�1rTR1 CAL PERMIT 'I hereby affirr- teat A have a certificate of consent to self insure, CE-806G 9i1 Ir LL 'i.r tfld!/9 or a certific^f=WS'rkers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY cppy� reof ($ec 3800,1_ah C) Policy NO -company FOR APPLICANT TO FILL IN JOB ❑• Certified copy is hereby furnished EACH NO FEE ADDRESS O2 4,010/2 1577 New Residential Bldgs & Pools S l Famiy, q Ft $ — $ LOCALITY T • -� Certified copy is filed with the county building inspection 1 & 2- department Multi-family Sq Ft NEAREST, , CROSS ST Date AppI Residential Swimming Pools OWNER OR FIRM NAME ,rl nA �yGr� licant �CJ CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec— Light Sw MAIL �� A �� j� COMPENSATION INSURANCE ADDRESS ,� V (This section need not be completed If the work involved by the First 20 Total No Additional CITY Tel No permit is for one hundred dollars ($100)or less.) PLAN CHECK I•certify that in the performance of the work-for which this permit APPLICANT 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 Additional Total No CITY Tel No Date Applicant Fixed Appliances Not Over 1 HPPERMIT _?;CT , NOTICE TO APPLICANT If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation Range_ Heater_ DW APPLICANT (A 2AILM provisions of the Labor Code,you,must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS provisions or this permit shall be deemed revoked Top — FAU _ WH LICENSED CONTRACTORS DECLARATIONCITY Tel No Hood Fan Other_ I hereby affirm that I am licensed under provisions of Chapter 9 Disp-- Room Air Cond LICENSE OR (commencing with Section 7000) of Division 3 of the Business and REG NUMBER Class Professions Code,and my licen"se is in full force and effect DISTRICT NO PROC BY Power Apparatus& Large Appliances Size&Type HP, KW,KVA,or KVAR ok. License Number Lic Class IUp to 1 Incl FINAL U Over 1 to 10 Incl DATE Contractor Date VALIDATION. Over 10 to 50 Incl U ❑ FINAL I am exempt under Sec Over 50 to 100 Inc BY W B&P C for this reason Over 100 � Services, Swbd,MCC & Panelboards Z Date 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 0 y, HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit r a I hereby affirm that-1 am exempt from the Contractor's License Law ACCT.It for the following reason (Section 7031 5, Business and Professions Additional Sign Branch Circuits Code), 33137 31.013 Tgf Misc Conduits& Conductors M Ty JLl` I,as owner of the property,will do the work and the structure 1 ITEM (=t 1� is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code) ® TTOTAL ,_ ® �� CONSTRUCTION LENDING AGENCY - CAN 31.00 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) t•�AN6E 'i"I Civ C) PLAN CHECKING FEE - Lender's Name PERMIT ISSUING FEE ✓ 00113-000 1 5116/9 ) - Leer's Address � 0 2431 1 AN 9:39 1 certify that I have read this application and state that the above TOTAL FEE information is correct I agree to comply with all County ordinances and State laws reg ating Electrical wiring, and hereby authorize represen ive is County to enter upon the above-mentioned property/ or in c es SEE REVERSE FOR EXPLANATORY LANGUAGE a � nat re O Vittee Date WORKERS'COMPENSATION DECLARATION C -663 10/81 APPUC MON FOR ELECTM L PERW I,hereby affirm that•I havera-cerhf:cate� of,consent to self.insure,- CE-806G /� ��f I�,i u Oil II'•6�!!@ ' 'or.a certificate d€Workers';Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy,thereof(Sec-3800•Lab C) Policy No Company FOR,APPLICANT TO FILL IN JOB ❑_ Certified copy is hereby furnishedNew Residential Bldgs &Pools EACH NO FEE ADDRESS. Certified copy is'filed with the county building inspection 1 & 2-Family,Sq Ft $ — $ LOCALITY department Multifamily Sq Ft — NEAREST1,� CROSS ST {� Date Applicant Residential Swimming Pools OWNER OR a� _ FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' 3—.! g � � [� MAIL , Outlets Rec Li ht t 2 b • COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work Involved•by the First 20 7rAl r, 6 Total No Additional CITY Tel No permit Is for one hundred dollars($100),or less) - , I certify that in,the performance of the work for which this permit PLAN CHECK Io an APPLICANT is issued, I shall not employ y y person in any manner so as to , become subject to the Workers'Compensation Laws Lighting Fixtures First 20 0 ADDRESS A Total No � dditionalCITY Tel No Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT If, after making this Certificate of Exemption,you should become subject to the Workers'Compensation Range HeaterL DW APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven Dryer L W M ADDRESS provisions or this permit shall be deemed revoked Top FAU WH LICENSED CONTRACTORS DECLARATION CITY Tel No _� � _ I hereby affirm that I am Hood Fan Other — Ilicensed under provisions of Chapter 9XLICENSE OR Disp Room Air Cond REG NUMBER Class (comrriencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect, DISTRICT NO P ESSED B Power Apparatus& Large Appliances a Size& Type HP, KW,KVA, or KVAR v(J 0 License Number Lic Class J G U Up to 1 Incl FINAL Over 1 to 10 Incl DATE Contractor Date VALIDATION O ❑ Over 10 to 50 Incl FINAL' I am exempt under Sec Over 50 to 100 Inc BY W B&P C for this reason Over 100 LL Services,Swbd,MCC& Panelboards I Date 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 i HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit s I hereby affirm that I am exempt from the Contractor's'License Law ANT°g for the following reason(Section 7031 5, Business and Professions Additional Sign Branch Circuits Code) 36 T c I,as owner of the property,will do the work and the structure Misc Conduits& Conductors 1`ITEMS is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code) TOTAL �. ? m qu� CONSTRUCTION LENDING AGENCY CHECK 151.80 I hereby affirm that there is a construction lending agency for the �+t�� performance of the work for which this permit is issued(Sec 3097, PERMIT FEE (Sub-Total) 'vfltSt`GE °00 Civ C) PLAN CHECKING FEE Lender's NamePERMIT ISSUING FEE O�t►O' o-DOD 1 8/23/9r_1 ' • Lender's Address �•- �°+-4 1 certify that I have read this application and state that the above TOTAL FEE information is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize represent five of this County to enter upon the above-mentioned propert ori on p rposes ' _ SEE REVERSE FOR EXPLANATORY LANGUAGE - Signa ure of Permittee Date ,