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Home My Public Portal About9507 LONGDEN AVE_Electrical__ ' 1 WOkKERS'COMPENSATION DECLARATION 76MW 10/81 hir ?� eby gffirm"'that`I have a certificate of consent to.self CE-806G APPLICATION FOR ELECTRICAL PERMIT rjns3re, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a cerfifid,�cPy�herr f Sec. 3800, Lab. C ) �v.,�, a/ Policy No'-� ?_�__O Company_ Y / u/1�1• FOR APPLICANT TO FILL IN JOB. Certified copy is hereby furnished. EACH NO. FEE ADDRESS d,� � New Residential Bldgs. &Pools ❑ Certified copy is filed with the county buil ing nspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY C� tion department. Multi-family Sq. Ft. — NEAREST p CROSS ST. Date �D^�'g�Applican Residential Swimming Pools OWNER OR CERTIFICATE OF EXEMP N FROM WORKERS' Outlets: Rec FNWIL NAME eN yr ' COMPENSATION INSURANCE Light • Sw._First 20 ADDRESS ,• ' g (This section need not be completed'if the work involved by Total No. Additional CITY Tel. No/– �v � the permit is for one hundred dollars($100)or less.) PLAN CHECK 1 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-- opplicant 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. r Compensation provisions of the Labor Code, you must forth- Oven _Dryer _W.M. ADDRESS �r �r Be)V– S with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. Hood —Fan _Other— CITY epiL e 1 . Tel.ltVor LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm thai I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER f !7 Class. (commencing with Section 7000)of Division 3 of the Business power Apparatus&Large Appliances DISTRICT NO. . PR C SED BY per"• and Professions Code,and my license is in full force and effect. off O Size&Type HP, KW, KVA, or KVAR o 0 V License Number L'ic. Class Up to 1 Incl. FINAL UO 1 Over 1 to 10 Incl. DATE VALIDATION Contractor Date Over 10 to 50 Incl.❑ FINA I W I am exempt under Sec. Over 50 to 100 Irtc. BY p„• Over 100 B.&P.C. for this.reason Z Date: Services,Swbd., MCC&Panelboords ► 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 8 Appurtenances Q , HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License & Law for the following reason (Section 7039.5, Business and Additional Sign Branch Circuits , Professions Code): # o o o o.o 2 ❑ I, as owner of the property, willdo the work and the Misc. Conduits&Conductors o 0 2 5 0 +structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ 17044, Business and Professions Code). , o - 25506 CONSTRUCTION LENDING AGENCY ( a 0 9 e 8 5 1 he�ebyiaffirm 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 to Lender's Address. I certify that I have read this application.and state that the TOTAL FEE S a ' above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize re es tatives of this County to enter upon - the ve- e ' n perty for inspectn purposes. J` Q,••o ,� SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee. Date WORKERS' I have a cerci DECLARATION i 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT I he;elJy affirm that I have a certificate of consent to self; CE-80613 insure,or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof(Sec. 3800, Lob. C.) Temple City 550115-86 State FundFOR APPLICANT TO FILL IN Policy No.. Company JOB 9507 I+OIl Certified copy is filed with the county building inspec- I Certified copy is hereby furnished. New Residential Bldgs. $Pools EACH NO. FEE ADDRESS 18 2-Family, q• s Ft2170 5.04 _ s g LOCALITY t tion department. Multi-family Sq. Ft. 'NEAREST Residential.Swimming Pools CROSS ST. Date 32/1-Ams Applicant J033V S EleCtr1Co OW R OR JaC,k WP.be>' CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE IFirst 20 ADDRESS 9501 Lcnaden (This section need not be completed If the work Involved by Total No. CITY Tel. No. the permit Is for one hundred dollars($100)or less.) Additional a Ci that in the performance of the work for which this I j PLAN CHEER I certify p 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 Additional +' Total No. CITY Tel. No. Date-- Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO, APPLICANT: If, after making this Certificate of APPLICANT J sS Electric: 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. i Flood Fan Oth er— CITY�lCkWM. park, CA. Tel. No. 338-2558 • _ — LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. ,— Room Air Cond. REG. NUMBER 259475 ClassClO— (commencing with Section 7000.)of Division 3 of the BusinessDISTRICT N PROC and Professions Code;and my license is in full force and effect. Power Apparatus 8 Large Appliances ` 4 /�,( 57 0 Size 8 Type HP;.KW, KVA, or KVAR' V (�u O i 9J License Number 259475 Lic. Class Cl0- Up to 1 Incl.' FINAL ?1 Vt S WeCl'Y' C10— Over 1 to 10 Incl. DATE — VALIDATION Contractor T 7>Jlrate Over 10 to 50 Incl. vvv p° ❑ FINA I am exempt under Sec. Over 50 to 100 Inc. BY IL Over 100 to B.BP.C. for this reason Services, Swbd.,MCC 8 Panelboards Z Date: I. 0'-200 Amp. Under 600 V Signature l 201 - 1000 Amp. Under 600 V ❑ Elect. Exemption for Reg. MainOver 1000 Amp. or Over 600 V Maine. Elect. SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER.DECLARATION :Sign with One Branch Circuit I hereby affirm th..at,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 M;se. Conduits 8 Conductors -��3 b 7.�A structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ # 0 0 0 0 0 2 7044, Business and Professions Code). I c o97,30 CONSTRUCTION LENDING AGENCY• I hereby affirm that there is a construction lending agency for o o o 9 7.3 0 5 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 2 1 7-185 (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name i . PERMIT ISSUING FEE �_10.50 Lender's Address I certify that I have read this application and state that the TOTAL FEE 9730 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 a 70 -mentioned ro rty for'�spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Arl2/i3/s5 ignatureYPermittee Date i