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HomeMy Public PortalAbout5745 OAK AVE_Electrical__ _--WORKERS COMPENSATION DECLARATION 76A663 10/81 CE 806G APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec 3800 Lab C ) Policy No Company FOR APPLICANT TO FILL IN JOB ADDRESS 7 S OAK Certified copy is hereby furnished New Residential Bldgs &Pools EACH NO FEE ❑ Certified copy is filed with the county building mspec 1 &2 Family Sq Ft $ — E LOCALITY tion department Multifamily Sq Ft — NEAREST Residential Swimming Pools CROSS ST ��K WOtZK M AAS Date Applicant OWNER OR s FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw_ MAIL COMPENSATION INSURANCE First ADDRESS SAmc (This section need not be completed If the work Involved by Total No Additional CITY Tel No Z47-7�6i the permit is for one hundred dollars($100)or less ) LAN 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 so as to become subject to the Worke Compensation Laws lighting Fixtures First 20 ADDRESS w Additional 6,,,�^A � Total No CITY No Date pplicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT If oft ► making this Certificate of APPLICANT Exemption you should become subject to the Workers Range_ Heater_D W AP Compensation provisions of the Labor Code you must forth- Oven _Dryer —W M _ ADDRESS with comply with such provisions or this permit shall be deemed revoked Top _ FAU _WH _ CITY Tel No LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ Disp Room Air Cond LICENSE Class I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER >„ (commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. „/ PROCESSE CL U and Professions Code and my license is in full force and effect Qy Size&Type HP KW KVA or KVAR License Number Lic Class Up to 1 Incl FINAL Over i to 10 Incl DATE VAUDA ON 0 Contractor Date Over 10 to 50 Incl I am exempt under Sec Over 50 to 100 Inc BY A Ld 1:1N B 8P C for this reason Over 100 Z Date Services Swbd, MCC 8 Ponelboards ► 0 -200 Amp Under 600 V Signature 201 - 1000 Amp Under 600 V ❑ Exemption for Reg MaOver 1000 Amp or Over 600 V mt Elect SINGLE FATY Temp Power Pole&Appurtenances HOME OWNER-BUILDER gCLARATION Sign with One Branch Circuit # e e e e •(�8 Q 8A A I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits • e 0 0 J0 Q 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)_ e . 925505 ► 7044 Business and Professions Code) Q 61 2-r86 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 Lenders Address � I certify that I have read this application and state that the TOTAL FEE 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 above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE nature of Permittee Date WORKERS COMPENSATION DECLARATION 8 ,o,a, APPLICATION FOR ELECTRICAL PERMIT {� I hereby affirm that I have a certificate ate of consent to self insure CE 806o8G LI 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 JOBADDRESS S~f S aA Avg ❑ Certified copy is hereby furnished New Residential Bldgs &Pools EACH NO FEE ❑ 1 &2-Family Sq Ft $ — $ LOCALITY Certified copy is fled with the county budding inspection NEAREST department Multi-family Sq Ft — CROSS ST , Date Applicant Residential Swimming Pools NER OR �- CERTIFICATE OF EXEMPTION FROM WORKERS 'a� MAIL NAME COMPENSATION INSURANCE Outlets Rec Light—S'.' ADDRESS 6-�PfS OAK Aye (This section need not be completed A the work Involved by the First 20 , permit is for one hundred dollars($100)or less) Total No Additional CITY �'1.n• �E Tel No Zg7-7�� I certify that in the performance of the work for which this permit PLAN CHECK is issued I shall not employ any person in any manner so as to APPLICANT become subject to the Workers Comp n iys Lighting Fixtures First 20 ADDRESS 1 —7 Additional CRY Tel No « 9� Total No Date la Applroa NOTICE TO APPLICANT I 49r making this Certificate Appliances Not Over 1 HP PERMIT ate of APPLICANT , Exemption you should become subject to the Workers Compensation Range_ Heater DW _ 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 _ WH _ _ LICENSED CONTRACTORS DECLARATIONCITY Tel No Hood _ Fan Other_ I hereby affirm that 1 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 E A Power Apparatus&Large Appliances DISTRICT NO PROCE ED BY��©� jU�( ` Size&Type HP KW KVA or KVAR O License Number Lac Class Up to 1 Incl FINAL Q / (� Contractor Date Over 1 to 10 Incl ai /o� r+ ��CJ VA LJ ATION p Over 10 to 50 Incl FINAL ❑ 1 am exempt under Sec Over 50-to 100 Inc BY A" a B&PC for this reason Over 100 V y Date Services,Swbd MCC&Panelboards , Z 0-200 Amp Under 600 V Signature 201 - 1000 Amp Under 600 V 13 Exemption 1000 Amp or Over 600 V Exemption for Reg Maint Elect 2 SINGLE FAMILY Temp Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit AWA 41.E I hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuitsfor the following reason(Section 70315 Business and Professions 3303 Code) 1 Ims ❑ I,as owner of the property,will do the work and the structure Misc Conduits&Corufuctors TOTAL 4130Other(See Complete Fee Schedule) �s not intended or offered for sale (Section 7044 Business and Professions Code) , - 41.30 CONSTRUCTION LENDING AGENCY owe .00 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) Q CN C) PLAN CHECKING FEE 0�0-Otm1 11/ 1/95 Lenders Name MIN 1 AH10:42 PERMIT ISSUING FEE Lenders 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 rep trves of this County to enter upon the above-mentioned roperty c ion oses� SEE REVERSE FOR EXPLANATORY LANGUAGE IFS-- /1�5ighature of Permittee Date