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Home My Public Portal About6133 MUSCATEL AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663. 10/81 t i.n I hereby"Affirm that I have a certificate of consent to self insure, CE-806G APPLICATION FOR ELECTRICAL PERK41T a',certiflcate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY �cdpy thereof(Sec.3800,Lab.C.) j Policy No. _� Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. ! EACH NO. FEE ADDRESS New Residential Bldgs•&Pools :LOCALITY 'Certified copy is filed with the county building1 &2-Family,Sq.Ft. $ _ $ l inspection „ department. Multi-family Sq.Ft. i.NEAREST Residential Swimming Pools CROSS ST. ` Date Applicant • IOWNER OR AIX £r MAU FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS" Outlets:Rec—Light_Sw.— ,MAIL COMPENSATION INSURANCE ADDRESS 1 (This section need not be completed if the work Involved by the t Total No. Addit oFirst pal 4CITY S Tel.No.2$2-0,660-'. . permit Is for one hundred dollars($100)or less.) I certify that in the performance jof the work for which,this permit 'f A PN CHECK 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 s Additional. Total'No. CITY Tel.No. Date Applicant i Fixed Appliances Not.Over 1 HP PERMIT ' NOTICE TO• APPLICANT: If, after making this Certificate of' APPLICANT OAI. �If✓E 1 C.•I Exemption,you should become subject to the Workers'Compensation.. s, Range_ Heater_ D.W. ; 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 S/�/V n` Tel.No f„4 r a68 LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ 1 hereby affirm that I am licensed under provisions of,Chapter 9 LICENSE OR DiSp. — Room Air Cond. REG.NUMBER �/ Class. 'Q '(commencing with Sec#ion 7000.),of Division 3 of.the.Business and ' Professions.Code,and my license is in full force and effect: Power Apparatus&Large Appliances DISTRICT N.O. / PROCESSED Y Size&Type HP,KW,KVA,or KVAR }; v V Q .License Number 67 3 f �" Lic.Class Up to 1 Incl. FINAL V �y� �A (q/C ��S_d Over 1 to'10 Incl. DATE VALIDATION O . Contractor QJ"r2y" Date O Over 10 to 50 Incl. FINA tU- ❑ I.am exempt under Sec. Over 50 to'100 Inc. gY WG. B.&P.C.for this reason Over 100 N 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.AAaint.Elect. rr j' I� .. SINGLE FAMILY Temp.Power Pole&Appurtenances �. • HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the.Contractor's License.Law' Additional Sign Branch Circuits Iti441 04 for the following reason(Section 7031.5,Business and Professions God e); 3307 25.50 Miso.Conduits&Conductors ❑. 1,as owner of the property,will do the work and the structure 1 ITM is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)-_ and Professions Code). POP'. TOTAL � 25 o 50 CONSTRUCTION LENDING AGENCY ' CECK 25.50 I hereby affirm that there is a construction lending agency for the performance of the wort(for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total) CHME -CO Civ.C.). • PLAN CHECKING FEE � 1V'��/6/15/89'Lender's Name O; mm—ami PERMIT ISSUING FEE _ , Lender's Address 40M 1 R11108856 1 certify that I have read this application and state that the above TOTAL FEE S information is correct.I agree to comply with all County ordinances I 4 and.State laws regulating Electrical. wiring, and hereby authorize , representatives.of this County to enter upon the above-mentioned y' p=tfo spection.purposes. i SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pertnittee a Date ORKERS'COMPENSATION DECLARATION 76A663 io/Si APPLICATIONFOR ELECTRICAL PERMIT (. tRfirm that I have a certificate of consent to self insure, CE `I 1 Sr a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY .copy therdof(See.3800.,Lab.C.) h Poi6,No.." Company ( FOR APPLICANT TO FILL IN JOB ❑ C rfified copy is hereby furnished. EACH NO. FEE ADDRESS I New Residential Bldgs &Pools aA LOCALITY 4;/A/ 4A.0 p,-,L CYtified copy is filed with the county building inspection ; 1 &2-Family,Sq.Ft.� $ _ $. NEAREST department. Multi-family Sq.Ft. CROSS ST. Date. Applicant Residential Swimming Pools OWNER OR t FIRM NAME rL ins — CERTIFICATE OF EXEMPTION FROM WORKERS' t Outlets:Rec—Light_Sw. , MAIL COMPENSATION INSURANCE• t. ADDRESS P Fl, - �• VJ'�A (This section need not be-completed if the work involved by the I First 20 ' j Total No. Additional CITY G',"72,�J�TeI.No. 7 permit is for one hundred hollers($100)or less.) ' I certifythat in the erformance of the work for which this permit PLAN CHECK P P APPLICANT _ is issued,'I shall not employ.any person in any..manner so-ad to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No. Additional CITY Tel.No. Date ApplicantFixed Appliances Not Over 1 HP PERMIT NOTICE TO, APPLICANT: If, :after making this ,Certificate of APPLICANT Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. — ' provisions of the Labor.Code,,youmust forthwith comply with such ':. Oven _ Dryer_ W.M._ ADDRESS,9 7 dr y//�r�,�/ provisions or this permit shall,be deemed revoked. Top _ FAU _ W.H. _ CITY s,jV 'slL— Tel.No. '.-a& LICENSED CONTRACTORS DECLARATION• Hood _ Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR Disp. ROOM Air Cond. REG.,NUMBER 73 Class. (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license-'is in.full.force and effect. ® °' DISTRICT NO. PROCESSED BY.. Al Power Apparatus&Large Appliances _ Q / 1�_.;�e Size&Type HP,KW,KVA,or KVAR �� License Number S �t'{ v h Lic.Class f I Up to 1 Incl. , FINAL " Contractor-MO !9 Gr &e. v� / - Over 1 to 10'I.ncl. DATE �^ -$ 9 VALIDATION 0 Over 10 to 10 Incl. FINAL Q!�"�"� ❑ I am exempt under Sec. Over 50 to 100 Inc: BY (� a • •B.&P.C.for.this reason. Over 100 U) Services,Swbd.,MCC&Panelboards ® Z Date: 0-200 Amp.Under 600 V �s .Signature 201 - 1000 Amp.Under 600 V ❑, Over 1000 Amp.or Over 600 V Exemption for Reg.MaintElect. ; SINGLE FAMILY Temp.Power Pole&Appurtenances 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that 1 am exempt'from the Contractor's License Law Additional.Sign Branch Circuits ACCTA for the following reason(Section 7031.5.,Business and Professions ' Code): r7,wt 117030 ❑ I;as owner of the property,-will do the work and the structure Misc..Gonduits&Conductors 1 ITEM Other(See Complete Fee Schedule) is not intended or offered for sale (Section 7044, Business p� and Professions Cade). TOTAL � �o � CONSTRUCTION LENDING AGENCY M r\K i 127.30 1 hereby affirm that there is a.construction lending agency for the "me performance of the work for which this-permit is issued(Sec.3097, PERMIT FEE (Sub Total) �p ■ Civ.C.). Lender's Name PLAN dHECKING FEE �ry e6 i PERMIT ISSUING FEE 3M 4 AH 9°32 Lender's Address , 1 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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Sibnature of PerrFilttee Date if O I ' i. =.� •..11t.,.�••/W-• - �1�� _ M•.1�:��/•'O•�•h�i^�:•w.OWy\/'� •Wj1Yn:1tEl1PP'OF �LTRs}Il�G;ATC'i � `tet � 9= •:-w� um OF LOS Aw.CM�B'. 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