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Home My Public Portal About5304 NOEL DR_Electrical_5/14/1985_ WORKERSirrnfh COMPENSATION DECLARATION CE8 G ,D,B, APPLICATION FOR ELECTRICAL PERMIT I herb4/ affirm feat-I`have a certificate of consent to self . insure ojha certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY ' or a cePrifed copy thereof(Sec 3800 Lab C ) Policy No Company FOR APPLICANT TO FILL IN JOB 5so`t Noel ❑ Certified copy is hereby furnished New Residential Bldgs &Ps s� $EACH NO E FEE ADDRESS T�f/'( 1 &2-Fomil Certified copy is filed with the county building inspec Y S q Ft LOCALITY tion department Multifamily Sq Ft NEAREST ,rte S' jgcj E. Residential Swimming Pools CROSS ST or.-(J Date Applicant LLT' OWNER OR v wA FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Li ht Sw_ MAIL /� COMPENSATION INSURANCE g ADDRESS $ 6AIAe.4wt4�( Aueo6 (This section need not be completed if the work involved by First 20 the permit is for one hundred dollars($100)or less ) Total No Additional y CITY ��G_ Tel No I certify that in the performance of the work for which this PLAN CHECK APPLICANT permit 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 NOTICE TO APPLICANT If after making this Certificate of APPLICANT.A �1 gZ QL L Exemption you should become subject to the Workers Range_ Heater_D W VX Compensation provisions of the Labor Code you must forth Oven _ Dryer _W M — ADDRESS 1Z'jJ 1301L with comply with such provisions or this permit shall be Top _ FAU —W H — p � deemed revoked Hood _ Fan _Other_ CITY t 1f��. Tel No q 7� LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER S(0 Class Z_(O (commencing with Section 7000) of Division 3 of the Business DISTRICT N • PROCE D BY and Professions Code and my license is in full force and effect Power Apparatus&Large Appliances y Y Size&Type HP KW KVA or KVAR r U O License NumberS6 Lic Class f Up to 1 Incl FINAL V Ate,- S C 8S Over I to 10 Incl DATE VA ATION Q Contractor �"�' � 'l Date ` ❑ Over 10 to 50 Incl FINA r I am exempt under Sec Over 50 to 100 Inc BY B&P C for this reason Over 100 in Date Services Swbd MCC&Panelboards 0 200 Amp Under 600V a 2 0 2 3 A Signature 201 1000 Amp Under 600 V ❑ Exemption for Reg Mainf Elect Over 1000 Amp or Over 600 V # e e e e e 2 I e e73.50 735O SINGLE FAMILY Temp Power Pole&Appurtenances HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit • - 73505 1 hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits 0 5 4-85 Law for the following reason (Section 7031 5 Business and Professions Code) ❑ I as owner of the property will do the work and the Misc Conduits&Conductors structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ► 7044 Business and Professions Code) 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 PERMIT FEE (Sub-Total) (Sec 3097 Civ C ) PLAN CHECKING FEE Lender s Name PERMIT ISSUING FEE 0 5,0 Lender s Address , I certify that I have read this application and state that the TOTAL FEE 3•S-6 r above information is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring and here authorize representatives of this County to enter upon I the a ve mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE 57/,(q 1 10,5- Signatur of Permittee Date WORKERS COMPENSATION DECLARATION ,OSB, APPLICATION FOR ELECTRICAL PERMIT 1 hereby a�rirm that f have a certificate of consent to self insure CE CE 806 DSG or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec 3800 Lab C) Policy No Company FOR APPLICANT TO FILL IN JOB a o U/�_ 1:1 Certified Residential Bldgs &Pools Certified copy is hereby furnished EACH NO FEE ADDRESS CJ F1 certified copy is f 1 &2-Family Sq Ft $ — $ LOCALITY department led with the county budding inspection Multi-family Sq Ft — NEAREST CROSS ST Residential Swimming Pools Date Applicant OWNER OR [[�� CERTIFICATE OF EXEMPTION FROM WORKERS FIRM NAME L� OG COMPENSATION INSURANCE Outlets Rec—Light —S—Sw ADDRESS e (This section need not be completed If the work Involved by the First 20 CIT C Tel No d ZI permit Is for one hundred dollars($100)or less) Total No AdditionalAe AoC PLAN .1 I certify that in the performance of the work for whlc Is r It APPLICANT CHECK is Issued I shall not employ any person In ny an so 0 become subject to the Workers Com do Lighting Fixtures IS Fust 20 ADDRESS Additional Total No CIT Tel No Dat/0/21/ Xq Applicant NOTICE TO AP LICANT If after mak is rtificate of Fixed Appliances Not Over 1 HP PERMIT Exemption you should become subject to the Workers Compens ion Range_ Heater DW _ APPLICANT— provisions PPLICANT—provisions of the Labor Code you must forthwith comply with ch Oven _ Dryer_ W M _ ADDRESS provisions or this permit shall be deemed revoked Top — FAU _ WH LICENSED CONTRACTORS DECLARATION Hood — Fan _ OtherCITY 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 Power Apparatus& Large Appliances DIST5R ,.N0 PRO ED BY Size&Type HP KW KVA or KVAR •(Vr�1, License Number Lic Class Up to 1 Incl FINAL ��y Over 1 to 10 Incl DATE _ /J� 0 Contractor Date ��VV VALIDATION � Over 10 to 50 Incl FINAL U ❑ I am exempt under Sec Over 50 to 100 IncBY W B&PC 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 SI Over 1000 Amp or Over 600 V ❑ Exemption for Reg Maint Elect , h SINGLE FAMILY Temp Power Pole& Appurtenances 3307 15■75 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractors License Law 1 ITEMS for the following reason(Section 70315 Business and Professions Additional Sign Branch Circuits Code) TOTAL 15.75 1[7f Misc Conduits&Conductors Imo, I as owner of the property will do the work and the structure Other(See Complete Fee Schedule) CHECK 15.75 is not intended or offered for sale (Section 7044 Business and Professions Code) CHANGE ■Q[I CONSTRUCTION LENDING AGENCY inn I hereby affirm that there is a construction lending agency for the QeiVV—QQQ1 11/10/89 performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub-Total) Civ C) 6b98 1 AM 9:17 PLAN CHECKING FEE Lenders Name PERMIT ISSUING FEE Lender s Address I certify that I have read this application and state that the above TOTAL FEE , information is correct I agree t omply ith all County ordinances and State laws gulat g El al w Ing and hereby authorize represe tives o th ount ante upon the above-mentioned prope for insp ct !o SEE REVERSE FOR EXPLANATORY LANGUAGE Si na re of rmitte ate