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Home My Public Portal About9646 LONGDEN AVE_Electrical__ �ArIQW ERS'COMPENSATION DECLARATION 7,6A663 10/81 APPLICATION FOR ELECTRICAL PERMIT that I Have a certificate of consent to self CE=8066ia certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY f(lya ified co t eof(Sec. 3800, Lab. C.) No � FOR APPLICANT TO FILL IN JOB P�o iicy No. Compa Certified co is hereb furnished. EACH NO. FEE ADDRESS 74v y P.Y Y New Residential Bldgs. &Pools ,..� 1 &2-Fomil q. LOCALITY /G Certified copy is filed with the county building inspec- y, S Ft: $ — $ � tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming Pools 10, CROSS ST. 7�7! i Date - Applicant OWNER OR y FIRM NAME 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. CIN �' Tel. No.�'7�'�33' the permit is for one hundred dollars($100)or less.) . Additional PLAN CHECK J� I 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 Additional Total No. " CITY I. No. Dat Applicga '�� Fixed Appliances Not Over 1 HP PERMIT NOTICE TO`APPLICANT: If, after akin Ing t Certificate of APPLICANT Aan 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. — deem.ed revoked' Hood Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE Hood _ Fan _Other_ . REG. NUMBER Clas I hereby affirm that I am licensed underDisp. Room Air Cond provisions of Chapter 9 S (commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PRO ES D BY :11- and Professions Code,and my.license is in full force and effect. Power Apparatus&Large Appliances '� �] ��75� Size&Type HP; KW, KVA, or KVAR' Vt `� O License Number Lic. ClassUp to 1 Incl. FINAL u ��_ � Over 1 to 10 Incl, DATE �� VALI ION ContractorQ Date Over 10 to 50 In . ❑ FINAL I am exempt under Sec. Over 50 to 100 Inc. BY 96 � 96 B.&P.C. for.this reason Over 100 Date: Services, Swbd., MCC&Panelboards 0 -200 Amp. Under 600V �2249A Signature 201 - 1000 Amp. Under 600 V Exemption fdr Reg. Mainf. Elect. Over 1000 Amp. or Over 600 V # o 0 0 0 0.2 SINGLE FAMILY 1. Temp. Power Pole.&Appurtenances ! S ;( 'o 0 2 5.5 0 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 7031.5, Business and Additional Sign Branch Circuits o o 0 2 S 5 05 Professions Code): I, as owner of the property, will do the work and the Misc. Conduits&Conductors O(� 2 -85 structure is not intended or offered for sale (Section Other(See Complete Fee 9chedule)- 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 No • Lender's Address i PERMIT ISSUING FEE (� G�/� 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 above-mention rty for inspection purposes.0-1 SEE REVERSE FOR EXPLANATORY LANGUAGE ! ignaIure of atee Date • I WORKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm"that I have a certifieate of consent to self CE-806G insure, or:a certificate of Workers'Compensation Insurance, COUNTY OF.LOS ANGELES TeWle City BUILDING AND SAFETY or a certified copy thereof(Sec. 3800, Lab. C.) Policy No. 5507 IS Company State � FOR APPLICANT TO FILL IN JOB EACH NO. FEE ADDRESS 96. Certified copy is hereby furnished. New Residential Bidgs. &Pools Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft..�R94 $ — $ LOCALITY tion department. Multi-family Sq. Ft. NEAREST� CROSS ST. . Date 12 a H AS Applicant-Je rg F.l tri Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw— IAD COMPENSATION INSURANCE DRESS 4275 N. Baldwin Ave. First(This section need not be completed if the work involved by Total No. Additional CITYJjcmte, Tel. N the permit is for one hundred dollars($1.00)or less.) PLAN CHECK I 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'Lows. Lighting Fixtures First ADDRESS Total No. Addittional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT.: If, after making this Certificate of APPLICANT J s S ElectricExemption, you should become subject to the Workers' Range_ Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven —Dryer _W.M.— ADDRESS3876 + 3:d.with comply with such provisions or this permit shall be • Top — FAU —W.H. — CIT Tel. No. deemed revoked. • Hood _ Fan _Other— 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 Class. Q.0- (commencing with Section 7000.)of Division 3 of the Business I DISTRICT NO PRO ED BY and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances i �t (/ I. Size&Type HP, KW, KVA, or KVAR' O License Number 259475 - —Lic. Class C3 0— Up to 1 Incl. FINAL W Over 1 to 10 Incl. DATE �� 09 Contractor EM:S r S Fl tee_ Date 7 ton OMS V ATION Over.10 to 50 Incl. FINAL W I am exempt under Sec. Over 50 to 100•Inc. BY B..&P.C. for this reason Over 100 Date: Services, Swbd., MCC&Ponelboards ® e 0 -200 Amp. Under 600 V .Signature 201 - 1000 Amp. Under 600 V 3'9.59 A ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. # o 0 0 0 0 2 SINGLE FAMILY Temp. Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ( o 1 6 6,2 6 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 g o o 16 6,2 6 5) Professions,Code): ❑ 1, as owner of the property, will do the work and the Misc. Conduits&Conductors 1.3 1 -8 6 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 10 Lender's Address I certify that I have read this application and state that the TOTAL FEE $166.26 ' 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 toenter upon the ve-mentione pro rty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 12/18/85 gnature o Per. i e+ Date