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Home My Public Portal About6412 OAK AVE_Electrical__ WORKERS'COMPENSATION DECLARATION ,78A883 ,D,a, APPLICATION FOR ELECTRICAL PERMIT 1 hereby affirm tf^iat I have a certificate,.611'consent 9 self insure, ,CE-aoeG or.i*,tificate^toA Workers' Compensation I�surance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY coplWhereof(fam 3800,Lab.C.) Policy No. Company &AN FOR APPLICANT TO FILL IN ,JOB / C /A ❑ ADDRESS (�^� Certified copy is hereby furhishedi New Residential Bldgs.& EACH NO. F E Certified copy is filed with the county building inspection i &2-Family,Sq.Ft. $ — $ OCALITY e department. ulti-family Sq.Ft. NEAREST esidentiai Swimming Pools CROSS Date � ~ Applicant�f��1"�IitQ� � OWNER O OR FIRM NAME 1N�. CERTIFICATE OF EXEMPTION FROM WORKERS' ts:Rec—Light_Sw.— MAIL COMPENSATION'INSURANCE I ADDRESS (This section need not be completed if the work involved by the First 20 permit Is for one hundred dollars($100)or less.) tall No. Additional PLANCITY Tel.No.Z��26�� I certify.that in the performance of the work fcr which this permit. pLICANT k Is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. UQ9 Fixtures First 20 ADDRESS Additional ,. Total No. CITY Tel.No. Date Applicant ixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMrr Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ APPLICANT r6 provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS 4 provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _. CITY Tel.No3 � � q �, .LICENSED CONTRACTORS DECLARATION tem Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE.OR (commencing with that. 7000)of Division 3 of the Business.and Disp. — Room Air Cond. REG.NUMBER ' f Class Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESS BY Power Apparatus&Large Appliances Size&'Type HP,KVV,KVA,or KVAR c lUi License Number Lim Class ��o Up to 1 Incl. FINAL V ` Over 1 to 10 Incl. DATE Jf VA ATION Contractor �. Date Over 10 to 50 Incl. FIN CJ ❑ 1 am exempt under Sec. Over 50 to 100 Inc. B LrJ BAP.C.for this reason Over 100 y Services,Swbd.,MCC&Panelboards ► Z Oq 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. SINGLE FAMILY Temp.Power Pole&Appurtenances ;1699.5A HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit. # o'o 0 coo 2 1 hereby affirm that I am exempt.from the .e Contractor's License Law Additional Sign BranchCircuits for the following reason(Section 7031.5,Business and Professions 'I o16(1,02 Code): I Misc.Conduits&Conductors o;0 16(1 0 2 5 ❑ I,.,as.owner of.the property,will do the work and the structure Other(See Complete Fee Schedule) _ is not intended or offered for sale (Section 7044,.Business and Professions Code). , o 5,0 8'-- 8 7 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 (Sufi Total) ,, Civ.C.). PLAN CHECKING FEE Lender's Name ' iw PERMIT ISSUING FEE �� Lender's Address / r I certify that I have read this application and state that the above TOTAL FEE ro information is correct.I agree to comply with all County ordinances and State laws reju�lat' Electrical wiring; and hereby authorize representative of unty to enter upon the above-mentioned prop for I p poses. SEE REVERSE FOR EXPLANATORY LANGUAGE Sighalure of Pe a Date };hrefeliYft"o' KERS.;:COMP11l5ATIOtJ,AECLARATiON C6 10/81APPLICATION FOR ELECTRICAL PERMIT�iiba�i:tf hd e a certifieafe of consent to selfitlsura ' ctificate of Workers'Cor;lpensation Insurance, COUNTY OF LOS ANGELES 'BUILDING AND SAFETY or a certipy thereof(Set. 3800, Lab. C.) •a. Poliy'y No. ` Company FOR APPLICANT TO FILL IN JOB ❑ Certified.co is hereby furnished. EACH NO.. FEE ADDRESS PY y ti New Residential Bldgs. &Pools ❑ 'Certified copy is filed with YFie'county building inspec-'i I &2-Family,Sq: Ft. $ _ — $ LOCALITY _ �� Ay tion department. Multi-family Sq. Ft. — NEAREST Residential Swimming Pools CROSS ST. Date Applicant OWNER OR CERTIFICATE-OF EXEMPTION FROM WORKERS' FIRM NAME IL COMPENSATION INSURANCE Outlets: Rec Light Sw._ AD ,DRESS I& I�k (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 + CITY .Y `,r®�� d Tel. No7/ �. I certify that in the performance of the work for which this PLAN CHECK / permit is issued, I shall riot employ any person in any manner APPLICANT 7edj / so as to become subject to.the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS O,' - oXA9 Datepplicant Total No. Additional CITY T I..Na�f _ . - A 'NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT- APPLICANT Exemption, you should become subject to the Workers' Range_ Heater=D.W. — 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 OtherCITY Tel. No. _Other— LICENSE CONTRACTORS DECLARATION LICENSE•OR _ /+ I hereby affirm that I am licensed under provisions of CDisp. Room Air Cond. hapter 9 REG..NUMBER: Class. --1 (commencing with Section y license of Division 3 of the Business power Apparatus&Large Appliances DISTRICT NO. _/ PROC SSED:BY dam' and Professions Code;and my license is in full force and effect: (o( �, Size-&Type HP, KW, KVA, or;KVAR License Number Lic. Class 1' Up to 1 Incl, FINAL Q r p Over 1 to 10 Incl. DATE �?✓ J VIDATION Contractor Date Over 10 to 50 Incl. (~� ❑ FINAL am exemptW under Sec. Over 50 to.100 Inc. BY D' B..&P.C. for this reason Over 100 Z Date: Services; Swbd.,MCC&Panelboards , 0 -200 Amp. Under 600 V Signature 201 . 1000 Amp. Under 600 V Over 1.000 Amp. or Over 600 V Exemption for Reg. Maint, Elect. �6425A SINGLE FAMILY Temp. Power Pole&Appurtenances # o '0 0 0,0 2 HOME OWNER-BUILDER DECLARATION 2 5 O Sigri with One BrSnch Circuit .o 0 I hereby affirm that I exempt from the Contractor's License I' Additional Sign Branch Circuits Law for the followingg r reason (Section 7031.5, Business and ' Professions Code): c—•: o c,o 2 5 5 0 5 ❑ 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)_ , 0 1.28 $7 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.). r PLAN CHECKING FEE Lender's Name PERMIT ISSUING.FEE Lender's 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 repr entatives of this County to enter upon the above-men on roperty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 7 ignature of Permittee :Date