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Home My Public Portal About9584 LOWER AZUSA RD_Electrical__ I WORKERS COMPENSATION DEC)4ARATION CE-806G (2 801 APPLICATION FOR ELECTRICAL PERMIT CE-806G I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING ANDPSAFETY insure or a certificate of Workers Compensation Insurance or a certified copy thereof(Sec 3800 Lab C) � 1 FOR APPLICANT TO FILL IN SOB Policy No4Y�.� 2 Company ` — ADDRESS � '/ New Residential Bldgs &Pools EACH NO FEE Certified copy is hereby furnished � ��/ 1&2 Family Scl Ft $ — Is LOCALITY lir F-1 Multifamily Scl Ft — NEAREST Certified copy a filed with t count buil inspection CROSS ST e- 61 dep rtm t Residential Swimming Pools OWNER OR j-i FIRM NAME / Date Applicant Outlets ReceLight�Sw Q ADDRESS b First 20 CERTIFICATE OF EXEMPTION FROM WORKERS Total No :Ff�— Additional L& CIT Tel No ��S66S� COMPENSATION INSURANCE } PLAN CHECK iZ APPLICANT O (This section need not be completed if the work involved Lighting Fixtures First 20 ADDRESS U by the permit is for one hundred dollars ($100) or less) /v Additional I certifythat in the Total No CITY Tel No O performance of the work for which this Fixed Appliances-Not Over 1 HP permit is issued I shall not employ any person in any manner PERMIT W so as to become subject to the Workers Compensation Laws Range_Heater APPLICANT p. Oven _ Dryer W M `/ ADDRESSN Date Applicant �n.� Top _ FAU _W H Z Hood _ Fan _Other_ CIT is ,lel No • 6 S/V NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ ICE OR Exemption you should become subject to the Workers REG NUMBS Class Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO LeD 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 VALID N 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 (commencingwithwith Section 7000)of Division 3 of the Busi Over 100 e ness and Professions Code and my license is in full force and effect Services License Nu er41 Lic Class 0 200 Amp Under 600 V 201 1000 Amp Under 600 V ' Contractor Date 7J Over 1000 Amp or Over 600 V HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits 90201 A ness and Professions Code) Misc Conduits&Conductors I as owner of the property will do the work and the Other(See Complete Fee Schedule)..— 2 • . 31L90 structure is not intended or offered for sale (Section 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY • • • 3 4.9 0 5 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub Total) 0 6 1 5—8 1 issued(Sec 3097 Civ C) Lenders 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 i above information is correct I agree to comply with all County i ordinances and State laws regulating Electrical wiring and 7 hereVW authorize re resentatives of this County to enter upon {{ th ove ntione property for inspection purp sea SEE REVERSE FOR EXPLANATORY LANGUAGE Sig ture of a ►t ee Date WORKERS COMPENSATION DECLARATION CE-806G (2 80) APPLICATION FOR ELECTRICAL PERMIT CE-806 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� ?. �9ZOM717 9/p��y s p/� FOR APPLICANT TO FILL IN JOB (� d Policy o Company //` Ary l'I� EACH NO FEE ADDRESS/-0Y.I6weA X &S 91) New Residential Bidgs &Pools Certified copy is hereby furnished4"-A_--eJ--- 1 &2 Family Sq Ft $ "- $ LOCALITY rj'E L,F C/jY ElCertified copy is filed with the county building inspection Multifamily Sq Ft CROSS ST { department �/�T`C..� TLC'��`/ Residential Swimming Pools OWNER OR FIRM NAME suPERG'llr� Date Applicant Outlets Rec_Light Sw MAIL nn First 20 ADDRESS G1 ®/Qf`,/ RJ" CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CIT4Fd V&, DCL W,,#kr.l No J73-SVMa COMPENSATION INSURANCE PLAN CHECK IL (This section need not be completed if the work involved APPLICANT V Lighting Fixtures First by the permit is for one hundred dollars ($100) or less) Additional Total No I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No U permit is issued I shall not employ any person in any manner PERMIT tti so as to become subject to the Workers Compensation Laws Range_Heater_D W APPLICANT T-g_ Te S/ S 0- Oven Oven _ Dryer_W M ADDRESS /� PC�/(�f� ,QT Z Date Applicant 1 Top _ FAU ^W H Hood _ Fan Other_ CITYC rslds/er# Tel No.3y�...e94., NOTICE TO APPLICANT If after making this Certificate of Disp _Room Air Cond_ LICENSE OR Exemption you should become subject to the Workers REG NUMBER�Ogseis� Class 4C—/O Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO P CE ED BY with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVAR .010 w deemed revoked l� Up to 1 Incl FINAL Over 1 to 10 Incl DATE eeyy' LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl VALI DAT I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL — 9 (commencing with Section 7000)of Division 3 of the Busi Over 100 BY ness and Professions Code and my license is in full force and effect Services License Number Lic Class �d 0-200 Amp Under 600 V (0-0 �'rf-��'� `� 201 1000 Amp Under 600 V Co rac or Date Over 1000 Amp or Over 600 V � HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances 17 Obe,<., B 0 0 2 5 A ' I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit # • • • • • 2 License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits _ ness and Professions Code) 2 • • 1 7 0 0 Misc Conduits&Conductors I as owner of the property will do the work and the Other(See Complete Fee Schedule)-- • • • 17 0 0 v structure is not intended or offered for sale (Section 7044 Business and Professions Code) 04622-8 CONSTRUCTION LENDING AOENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is Z14- PERMIT (Sub Total) eef issued(Sec 3097 Civ C) de 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 informationis orrect I agree to comply with all County �, 9 ordinances and S to laws regulating Electrical wiring and hereby authoriz r tatives of this County to enter upon the above ed prop y for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature o mittee Date