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Home My Public Portal About4700 F MILLER DR_Electrical__ WORKERS'COMPENSATION DECLARATION I 76-863 10/81 APPLICATION FOR .ELECTRICAL PERMIT I hemby,dffirm that I have a certificate of consent to self insure, + CE-806G 'j or a,certificate of Workers' Compensation Insurance,or a certified I COUNTY OF LOS ANGELES BUILDING AND SAFETY i copy•thereof((Banc:38'0s0r:Lab.C.) L'' Policy ��pmpany.- r�+�p N6!1'b FOR APPLICANT TO FILL IN JOB `�/ �) Q., Certified;co y is hereby furnished. �: EACH NO. 'FEE ADDRESS cw ��Le� //� p New Residential Bldgs.&'Pools 1 &2-Family,Sq. $ — $ LOCALITY 7 1-." ov j Certified copy is filed. with the county building in I — NEAREST _ department. Multi.-family Sq.Ft. CROSS ST iy Date Applicantas',( Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' O 'T Outlets:Rec Light Sw. Z MAIL ! — COMPENSATION INSURANCE 0 ADDRESS �Il� /Lra (This section need not be completed:if the,work involved by the r First 20 �� I Permit Is for one hundred dollars($100)or less.) i' Total No. Additional CITYAfOAJ40viot." "fel.NO.?S 3�1/ PLAN CHECK 1 certify that in the performance of the work for which this permit' I'll APPLICANT is.issued, I shall not employ any person in any manner so as to become subject to the•Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional • . CITY Tel.No. Date Applicant I Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT ;$'.� G Exemption,you should become.subject to the Workers'Compensation Range_ Heater provisions of the Labor Cod e,,you.must forthwith comply,with such Oven _ Dryer_ W.M._ +' ADDRESS O lZ ST provisions dr this permit shall be deemed revoked. ; Top — FAU _ W.H. _ ��p LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY �'� �� T.I.N�Tl��/ I hereby-affirm that, I am licensed under provisions of Chapter 9 ' : LICENSE OR (commencing with Section 7000)of Division.3,of the Business and Disp. — Room Air Cond. Ciasa n l REG.NUMBER /�O of lV Professions Code,and my license is in full force and effect. I Power Apparatus&Large Appliances + DISTRICT NO. PRO'SSED BY >'' I Size&.Type HP,KW;.K.VA,or KVAR f D� �Q" License Number ,4 Lic.Class I, ,Up to 1:Incl. aple d FINAL �+ Contractor s6t �4e CIE Date Z-— — / I' Over 1 to 10 Incl. i• DATE VALIDATION �/'. VALIDATION 0 Over 10 to 50 Incl. FINAL 1117......'... I am exempt under Sec. Over 50 to 1.00 Inc. ♦ gYW B.&P.C.for this reason Over 100 Services,,Swbd.,MCC&PanelboardsI. ONO.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 ' HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit hereby affirm that 1 am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions p Additional Sign Branch Circuits T- Code): + "a�1I -'r i Misc.Conduits&Conductors L{�'.1. 0 I,as owner of the property,will do the work and the structure' +''TLN `•'r_ is not intended.or offered for sale'(Section 7044, Business I. Other(See Complete Fee Schedule) _ I , i,1 - and Professions Code). ® TOTAL' .�'a 6- 3 CONSTRUCTION LENDING AGENCY + } l=i•��, ,1[•li I hereby affirm that there is a construction lending agency for the " - n' performance of the work for which this permit is issued(Sec.3087, PERMIT FEE (Sub Total) t; �j gt. nt(q Civ.C.Q.' PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I TOTAL FEE r� / 94 SO 1 A v.I I certify that I have read this application and state that the above I oC'(oi i3 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-mentioned. ; property i pection pu as. I' SEE REVERSE FOR EXPLANATORY LANGUAGE na we of liffrmittee, Date WORKERS'COMPENSATION DECLARATION 20'0019DPW 3/� APPLICATION FOR ELECTRICAL PERMIT O hereF3y affirm••that 1 lia+ve a certificate of consent to,self CE-806G 4 insere;or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a.certi i d copy thereof(Sec. 3800, b. C.) . Polic�iYo �- ompany �14 FOR APPLICANT TO FILL IN JOB ❑Certified to is hereby furnished. p ADDRESS �� /C�/� L°� ✓L' PY Y �" -% New Residential Bldgs. &Pools EACH NO.' FEE' " ertLOCALITY ified copy is filed with the county building inspec- 1 8 2-Family, Sq. Ft. $ — $ � e tion department. �.%/ Multi-family Sq. Ft. NEAREST CROSS ST. , Date-_/`y -q/ Applicant S K. C' Residential Swimming Pools OWNER OR FIRM•NAME CERTIFICATE OF EXEMPTION FROM WORKERS' � � MAIL Outlets: Rec Li ht Sw. i ati1�• , dap COMPENSATION INSURANCE • g First 20 G G0 O ADDRESS • Y`'' ,' (This section need not be completed if.the work involved by Total No. Additional ,�iO Fj 'CIN "�a� Tel. f the permit'is for one hundred dollars(:100)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 fighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. L � Additional Date Applicant Total No.- CITY Tel. No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over I HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. _ APPLICATION ��' �'• .��'�/ 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. Hood — Fan _A_-Other— CI • Tel. N 79 LICENSED CONTRACTORS DECLARATIONS 7 d0 LICENSE-OR Disp. — Room Air Cond. _ Class.C`Q NUMBE (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. ESSED BY d and Professions Code,and my license is in full force and effect. r,} Size&Type HP; KW, KVA, or WAR :[/ O License Number 4KZ72 0 9 Lic. Class Up to 1 Incl. FINAL V Over 1 to.10 Incl. DATE � '-I I/ „(/ VALIDATION 0 Contract ��s Dafe. J Over 10 to 50 Incl. FINAL _ `( Over 50 to 100 Inc. BY ❑ U II.am exempt under Sec. LLI B.&P.C. for this reason Over 100 a 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 Tem Power Pole&Appurtenances y HOME OWNER-BUILDER DECLARATION P' PP I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit ? Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 330 j '�:i.,,,,! Professions Code): El I.; ' ` �as owner of. the property, will.do�the work andMisc. Conduits.&Conductors i 104 .the structure is not intended or offered for sale(Section 7044, Other'(See Complete Fee Schedule)_ I OTAL, 94. 3 13 Business and Professions Code). ® -tet t- ;- CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for NAWGRE AL"! the performance of the work.for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE '+ E Lender's Na.rrle ( II�i?-1��Ilj� `j� 71 LendPERMIT ISSUING FEE 18;5 16 1 Arl 9:Y Lender's Address 3Q I certify that I have read this application and state that TOTAL FEE the 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 abo m Toned.pro for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of P it ee -' Date ®'