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HomeMy Public PortalAbout5941 MUSCATEL AVE_Electrical__ I WORKERS'COMPENSATION DECLARATION 78-889 10/81 APPLICATION FOR ELECTRICAL PERMIT {� I hereby affirm that I have a certificate of consent to self insure, �CE-80613 LJ or a certificate of Workers' Compensation Insurance, or ace "ed COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof S c� 8 Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB J� /�d � ❑ EACH NO. FEE ADDRESS (J (f C, Certified copy is hereby furnished. New Residential Bldgs.&Pools ❑ 1 &2-Family,Sq.Ft. $ — $ LOCALITY rpriii py is filed with the county building inspe ion NEAREST Multi-family Sq.Ft. — Residential Swimming Pools CROSS ST Date Applican OWNER OR a.. Zr FIRM NAME �} CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL Outlets:Rec—Light—Sw.— COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the First 20 y �� permit Is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.N . PLAN CHECK I certify that in the performance of the work for which this permit P 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 i Additional CITY Tel.No. Date Applicant. Total No.Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT _ Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ APPLICANT provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top — FAU _ W.H. CITY T.I. LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9Disp. — Room AiCdLICENSE OR ron . (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER (pqn if Class. Professions Code,and my license Is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. �+'p © OCESSED BY >; IL Size&Type HP,KW,KVA,or KVAR S• ,v O O License Number Lic.Class Up to 1 Incl. FINAL V �j { Over 1 to 10 Incl. DATE 1��� QJ VALIDATION O Ilt ContractorF'd��--��+ ` Date Over 10 to 50 Incl. FINAL U ❑ I am exempt under Sec. Over 50 to 100 Inc. BY �W BAP.C.for this reason Over 100 Cl) 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. 2 SINGLE FAMILY Temp.Power Pol Appurtenances ACCT.lar HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 3303 70.10 1 hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits ►� for the following reason(Section 7031.5,Business and Professions 1 ITEI-13 Code): TOTAL �/0 o �I Q ❑ Misc.Conduits&Conductors I,as owner of the property,will do the work and the structure �+11: . is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 4.I!—C% 70.10 and Professions Code). ® CHME .60 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(Sec.3097, PERMIT FEE (Sub-Total) QQQIID1 11�13�9 Civ.c.). 3269 1 t!�1 9.03 PLAN CHECKING FEE Lender's me O PERMIT ISSUING FEE Lender dress I certi hat I have read this ap licati and state that the above I TOTAL FEE infor on is correct.I agree to compl with all County ordinances and t to laws regulating a ncal iring, and hereby authorize rep ntatives of this Cou a upon the above-mentioned pro f 1 pec ion PL �s SEE REVERSE FOR EXPLANATORY LANGUAGE ~C Sig ture ofPermittee Date WORKERS'COMPENSATION DECLARATION 78-803 10/81 APPLICATION FOR ELECTRICAL PERMIT {� I�hereby.affbm the I leve a certificate of consent to self insure, CE-806G Ll or a certlicke of".Wprkers'botnpensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3600.Lab!C.) _ Policy No. 6 Lm 5-ZZ Company �7tty ` —ice FOR APPLICANT TO FILL IN JOB ❑ _ EACH NO. ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Poo s FEE LOCALITY Certified copy is filed with the county building ins ction 1 &2-Family, de rtment. Multi-family Sq.Ft. NEAREST } CROSS ST. Date — ` Applicant Residential Swimming Pools OWNER OR /�O FIRM NAME ('} / CERTIFICATE OF EXEMPTION FROM RKERS' Outlets:Rec—Light_Sw.— MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed If the work involved by the First 20 permit is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.No. I certify that in the performance of the work for which this permit PLAN CHECK 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 Fixed Appliances Not Over 1 HP PERMIT ,9 NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT (;12 C �� �-- Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS 3 Z 3 y-H L 5 provisions or this permit shall be deemed revoked. Top — FAU _ W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY G true ,LLS Tel.No. Syv 33C?, S 0 I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE R Disp. — Room Air Cond. (tL (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER J it Class. C�! Professions Code,and my license is in full force and effect. `/U Power Apparatus&Large Appliances DISTRICT NO. PRC SED BY j 33 y4 Size&Type HP,KW,KVA,or KVAR +Nj 1 ,� U Licensee Number Lic.Class(/n� Up to 1 Incl. FINAL ^' �Contr #br- �t7 L�� L Date �� Over 1 to 10lncl. DATE VALIDATION Q ❑ Over 10 to 50 Incl. FINAL 1 am exempt under Sec. Over 50 to 100 Inc. BY W Over 100 fl B.&P.C.for this reason to Services,Swbd.,MCC&Panelboards atm 0-200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Main/ Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit R�C ev I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5,Business and Professions .Additional Sign Branch Circuits 333 316005 Code): ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 ITEM is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ ® TOTAL �- o 00-5and Professions Code). CONSTRUCTION LENDING AGENCY CHANGE 316.05 1 hereby affirm that there is a construction lending agency for the. \rllANGE .00 performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Civ.C.). PLAN CHECKING FEE (Egg-GM1 12/ 6/95 Lender's Name PERMIT ISSUING FEE oC L) 3611 1 AN10°31 Lender's Address I certify that I have read this application and state that the above TOTAL FEE 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 proper for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Si nature of Z7 ffirttee Date