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Home My Public Portal About6243 MUSCATEL AVE_Electrical__ WORKERS'COMPENSATION DEi LARATION CE-806G10is1 APPLICATION FOR ELECTRICAL PERMIT I hereby,ajfir% that I have arcertlflcate of consent to self insure, e or e•certific9te of orkerg' Compensation InsUiance, oi•a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800.Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOBUzi �� ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS ❑ 1 &2-Family,Sq.Ft. $ —Is LOCALITY Cortifiod copy is filed with the county building inspection NEAREST , department. Multi-family Sq.Ft. CROSS ST �0�- Date Applicant Residential Swimming Pools OWNER OR iQJ -C' FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' � � r�G.� /�3 MAIL Outlets:Re Light Sw. COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the �'''jx First 20 permit is for one hundred dollars($100)or less.) Total No.�--1� Additional U C' GtITY `�C� Tel.No. -% OZ;L I certifythat 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 20s _ ADDRESS Total No., Additional '-2 CITY Tel.No. Date Applicant 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. L APPLICANT provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M.L ADDRESS provisions or this permit shall be deemed revoked. Top — FAU W.H. �/ ems§ CITY LICENSED CONTRACTORS DECLARATION Hood Fan Other_ Tel.No. I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. LICENSE OR Class. (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSED-BY _ Power Apparatus& Large Appliances _ [Z1�. Size&Type HP,KW,KVA,or KVAR License Number Lic.Class Up to 1 Incl. FINAL Over 1 to 10 Inc]. /+QQ/b Gr DATE FINALr t _ -� VALIDATION 0 Contractor Date Over 10 to 50 Incl. 0 ❑ V I am exempt under Sec. Over 50 to 100 Inc. BY lJJ BAP.0 for this reason Over 1 V N Servic bd. M G&Pane ,r _ Z Date. - 00 Am Under 600 V 4 r'' Signature 201 - 1000 Amp.Under 600 V RRA a ❑ L t,i a s Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V 247.il, SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 1 I T EMM I hereby affirm that I am exempt from the Contractor's License Law fC(7i1L for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits . ode): CHEu1'% 24-1 'IQt 1IrC�E I,as owner of tho property,will do the work and the structure Misc.Conduits&Conductors +.�-(��13E is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). _ CONSTRUCTION LENDING AGENCY 1 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 ($ub Total) ,J i 2912 1 AM 7:51 Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the above TOTAL FEE information is orrect. agree to-comply with all County ordinances and S a regula i Electricaf`viring, and hereby authorize repres ves is C my to r upon the above-mentioned per Q ms + pu SEE REVERSE FOR EXPLANATORY LANGUAGE Sign km wee Oate DEC TION WORKERS'that I have a cerci cafe of corse 20.0019 DPW 3/07 APPLICATION FOR ELECTRICAL PERMIT Aw6y affirm that I have a certificate of consent to se f CE" insure, or a cert?ficate of Workers'Compensation Insuranc , COUNTY OF LOS ANGELES DEPT. OF PUBLIC WOR &kizzor a certified copy thereaf(Sec. 3800, Lob. C.) Policy No. Company FOR APPLICANT TO FILL IN SOB ❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS '60-43off ❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. Ft. CEASES T. D/�! Date Applicant Residential Swimming Pools OWNER OR ITA FIRM NAME CERTIFICATE OF EXEMPTION TOM WORKERS' Outlets: Rec Light Sw._ MAIL First 20 COMPENSATION INSURANCE ADDRESS rL This section need not be completed if the work Involved by CITY Tel. No. the permit is for one hundred dollars($100)or less.) Total No. Additional /f 7 9. -/ /( I I certify that in the performance of the work for which this PLAN CHECKAPPLICANT permit is issued, I shall not employ any person in any manner so as to become subject to the Workers ompensation Laws. Lighting Fixtures First 20 ADDRESS Additional Date lo- -845 Applicant Total No. CITY Tel NOTICE TO APPLICANT: If, after king thi C rtificate of Fixed Appliances Not Over 1 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 —other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. — REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances ; DISTRICT NO. PROCE ED BY >_ and Professions Code,and my license is in full force and effect. ,` d Size&Type HP, KW, KVA, or KVAR .�e' V (Y O License Number Lic.Class Up to 1 Incl. FINAL i Over 1 to 10 Incl, j DATE // JI IDATION Contractor Date Over 10 to 50 Incl. FIN o O ❑ I am exempt under Sec. Over 50 to 100 Inc. BUUI „ U B.&P.C. for this reason Over 100 Services, Swbd., MCC&Panelboards Date: !f Z 0-200 Amp. Under 600 V Vfpd( Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. ! C 8 2 8 A SINGLE FAMILY Temp. Power Pole&Appurtenances c HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # o o 0 0 0 2 1 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 ) 0 2 5,5 G Professions Code): o 0 0 2 5.5 0 ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Scheduled , L) 60c, _68 Business and Professions Code). CONSTRUCTION LENDING AGENCY i 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 6 Lender's Address r '` I certify that I have read this application and state that the TOTAL FEE J I J U above information is correct. 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