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Home My Public Portal About8628 LONGDEN AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 , /� nD nQ C /� MN FOR E ECT. C n p PER n/1 Y CE-8o6G (2-so) G�11TIrl� (�1 I1V FOR LSL�L� I111�C �1L; II LSII�COVU U I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate ol,Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C.) Policy No, Company � r FOR APPLICANT TO FILL IN SOB ! �T New Residential Bldgs.&Pools EACH NO. FEE ADDRESS �c rtified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ . _ $ LOCALITY aMulti-family Sq. Ft. — NEAREST Certified,copy is filed with the unty building inspection CROSS ST department. Residential Swimming Pools OWNER OR q e Applica FIRM NAME Dat /Y V Outlets: Rec./—Light—Sw. AIL E CERTIFICATE OF EXEMPTION FROM WORKERS' First ADDRESS COMPENSATION INSURANCE Total No.. Additional CITY � �•Tel No. 70 PLAN CHECK } APPLICANT Q (This section need not be completed if the work involved Lighting Fixtures First 20 U by the permit is for one.hundred dollars ($100) or less.) Additional ADDRESS Total No. I certify that in the performance of the work for which this CITY Tel No. 0 Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any manner - PERMITV so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT417bn1C W a Oven _ Dryer_W.M._ ADDRESS U .LIST U) Date Applicant' Top FAU X—W.H.. _ Hood Fan —Other— CITY Tel Noyo NOTICE TO APPLICANT: If, after making this Certificate of Disp. = Room Air Cond. ICENSE OR /} Exemption, you. should become ,subject to the Workers' REG.NUMBER ,1 O Class Compensation'piovisions 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. FINAL Z_ Over 1 to 10 Incl. DATE �®S" VALIDATION LICENSED CONTRACTORS.DECLARATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000) of Division Y of the Busi- Over 100 BY - ness and Professions.Code, and my license is in full force and effect. Services License Numb �7S/ Lic.Class a �` 2-60-200 Amp. Under 600 V 201-1000 Amp. Under 600 V Z22P Contractor t �/-� Date ofOver 1000 Amp.or Over 600 VHOME OWNER-BUILDER DECLARATION Temp.Power Pole&AppurtenancesI -hereby affirm that I am exempt t'rom the Contractor's Sign with One Branch Circuit 3,9'A License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuitsness and Professions Code): _ ° 2 Misc.Conduits& Conductors I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 1 t° 'O 2 1.7 Jr structure is not intended or offered for sale (Section 7044, Business and Professions Code). " _ CONSTRUCTION LENDING AGENCY °.° ° 2 1.7 5.0 I hereby affirm that there is a construction lending agency 09.2 4—8 2 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 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 ab mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Date WORKERS'COMPENSATION DECLA;P.ATi6N 768063 (2-SO) APDL ICA Il ��11C1 FOR ELEC p PUCAL�. I�LSII\CI1Gl1� 11 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.) a FOR APPLICANT TO FILL IN'. ,JOB 11 p� Policy No. Company EACH NO. FEE ADDRESS New Residential Bldgs.&Pools Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY 6 Multi-family Sq. Ft. — NEAREST EJ Certified copy.is filed with the county building inspection CROSS ST Residential Swimming Pools department. OWNER OR FIRM NAME //'' /��/l (� Date Applicant Outlets: Rec Light Sw. �� ADDRESS 01�� — �--QNGD CERTIFICATE OF EXEMPTION FROM WORKERS' A''� First 20 COMPENSATION INSURANCE Total No. 6 J Additional CITY Tel No. �,� -3i? PLAN CHECK CL / (This section need'not be completed if the work involvedi APPLICANT- 0 '/toy. O• • by the permit is for- one hundred dollars ($100) or less.) Lighting Fixtures First 20ADDRESS , 0 ' Additional it � Total No.� I certify that'in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. 01 permit is issued, I shall not employ any Pers in any manner — PERMIT so as'to become subject to the Workers' C m ensation Laws. Range_ Heater_D.W. APPLICANT W nn Oven ._ Dryer_W.M. ADDRESS ' to ate AppliTop =FAU _W.H. cant Hood Fan _Other_ CITY' Tel No. NOTICE TO APPLICANT: If, after making this 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. PROCES ED BY with comply with such provisions or this permit shall be' deemed revoked. Size&Type HP, KW; KVA,or'KVAR . 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 04 BY . 9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 5 ness and Professions.Code, and my license is in full force.and effect. Services ((1/ g License Number38131 LLic.Class ® 0-200 Amp. Under 600 V ��•, , 201-1000 Amp. Under 600 V Contracto/0�� i"74K/4KDate � Over.1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances t from the Contractor's Sign with One Branch Circuit I hereby affirm that I am exempt Additional Sign Branch Circuits 2.b 1 1,9•A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): # o 0 0 0 o2 Misc.Conduits&Conductors El I, as owner of the property, will do the work and the Other(See Complete'Fee Schedule)— 2 °-O 33 1'0' structure is not intended or.offered for sale (Section - 7044, Business and Professions Code). '010 0 3,3 1.0= CONSTRUCTION LENDING AGENCY U I hereby affirm that there is a construction lending agency 0 9.0 9—8.2 for the performance of the work for which this permit is PERMIT FEE (Sub-Total) 2 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 t ove-mentione property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature Permittee Date n