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Home My Public Portal About9111 OLEMA ST_Electrical__ r WORKERS'COMPENSATION DECLARATION 78-863 10/8 CE-808G 1 APPLICATION FOR ELECTRICAL PERMIT xa ;. ,a(thereby affirm that I fiave:a certificate of sonsent to,self 1na:ure, er a certificate of Workers' Compensation Insurance, or a.certified COUNTY OF LOS ANGELES BUILDING AND SAFETY cit .thereof(Sec .3800,Lai{C.) P114 No. Company FOR APPLICANT TO FILL IN JOB a ) J DDRESS O e �^f A 7�/f ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pgols EACH NO. FEE s ❑ 1 &2-Family,.Sq:Ft.. $ — $ LOCALITY Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. — NEAREST CROSS ST. Residential Swimming Pools OWNER R ' Date Applicant27 /�) FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light 3 Sw.-21 / MAIL c� • COMPENSATION INSURANCE ADDRESS II OLS 51;r(This section need.not be completed If the work Involved by the 1, First 20 permit.is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.Nog 90, I certify that in the performance of the work for which this permit I 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 20 ADDRESS Additional Total No. CITY Tel.No: Date Applicant Fixed Appliances Not Over 1 HP 46TICE TO APPLICANT: If, after making this Certificate of PERMIT %r Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT •s- N Q 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. LICENSED CONTRACTORS DECLARATION Hood — FanCITY Tel.No. I hereby affirm that 1 am licensed under provisions of Chapter 9 -�-- Other_ Disp. — Room Air Cond. 15 LICENSE OR (commencing.with Section 70.00)of Division 3 of the Business and REG.NUMBER Cilass.. Professions Code,and my license is in full force and effect. DISTRICT No. PR SED ;Power Apparatus&Large Appliances Size&Type HP,KW,KVA,or KVAR ' joy t O License Number Lic.Class ! Up to 1 Incl. FINAL V Over 1 to 10 Incl. DATE, VALIDATION Contractor Date Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY /Z_ � '� W B.&P.C.for this reason i 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.Maint.Elect. SINGLE FAMILY ! Temp.Power Pole&Appurtenances - 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit n g. I hereby affirm that I am exempt from the Contractor's License Law A4,. A for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits _ Code): 330! 27.011 Eli,as owner of thoffered will do the work and the structure is not intended or offeredred Other(See Complete Fee Schedule)Misc.Conduits&Conductors 1 ITEMS for sale (Section 7044, Business TOTAL 27. 00. and Professions Code). CONSTRUCTION LENDING AGENCY CHECK 27'00 I hereby affirm that there is a construction lending agency for the CHANGE .00 performance of the work for which this permit is issued.(Sec.3097, PERMIT FEE (Sub Total) ` Civ.C.). PLAN CHECKING FEE 0000-1001 v/20/90 Lender's Name PERMIT ISSUING FEE1.3 2475 1 AM ,6.211 Lender's Address y, I certify that I have read this application and state that the above TOTAL FEE iJ 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 in ores. SEE REVERSE FOR EXPLANATORY LANGUAGE 91127 1 of Permittee Date WORKERS'COMPENSATION DECLARATION 4 C 8oeG 1 c/81 APPLICATION FOR ELECTRICAL PERMIT , I�hereby affirm that I have�a certificate of Consent td•self irralure,++ or a certificate of Workers' Compensation Insurance, or a certified �; COUNTY OF LOS ANGELES BUILDING AND SAFETY thereof(Sec.3800,LatVC.) f Polio NO. Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished.. New Residential Bldgs.&Pools EACH NO, FEE ADDRESS ❑ I 1 &2-Family,Sq.Ft. $ _ $ LOCALITY Certified copy is filed with the county building ipspection department. Multi-family Sq.Ft. NEAREST CROSS ST. Date Applicant I Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: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.) p Total No. Additional CITY Tel.No. I certify that in the performance of the work for which this permit I PLAN K 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 Additional Date q n Applicant �• Total No. CITY Tel.No. NOTICE' TO APPLICANT: If, •after ing this Certificate of ;Fixed App lances Not Over 1 HP PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ APPLICANT provisions of the Labor Code,you must forthwith comply with such Oven Dryer_ W.M._ ADDRESS provisions or this permit shall be deemed revoked. + Tgp _ FAU _ W.H. _ • LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY Tel.No. I hereby affirm that I am licensed. under provisions -of Chapter 9LICENSE OR Disp. — Room Air Cond. REG.NUMBER Class. (commencing with Section 7000)of Division 3 of the Business and +' Professions Code,and my license is in full force and effect. r Apparatus&Large Appliances DISTRICT NO. PROCESSED BY I Size&Type HP,KW,KVA,or KVAR : Q U License Number Lic.Class. f Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE VALIDATION Contractor . Data Over 10 to 50 Incl. !T J ElI am:exempt under Sec. I Over.50 to 1FINAL.00 Inc: BY a B.&P.C.for this reason Over 100 N Services,Swbd.,MCC&Panelboards / p Z Date: 9-200 Amp.Under 600 V e Signature �; 201 - 1000 Amp.Under 600 V ❑ Exemption for Reg.Maint.Elect. i• Over 1000 Amp.or Over 600 V 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 for the following reason(Section 7031.5,Business and Professions dltional Sign Branch Circuits _+ Code): y^ M!so.Conduits A Conductors I: ACC•1°e ❑ i,as owner of the property,will do the work and the structure I. Other(See Complete Fee Schedule) _ 6307 i 1 j] is not intended or offered for sale (Section 7044, Business e and Professions Code). - 1 CONSTRUCTION LENDING AGENCY 1 ITEM f e TOTAL *=' -® 0 1 hereby affirm that there is a construction lending agency for th performance of the work for which this permit is,issued(Sec.3087, PERMIT FEE (Sub Total) �� + " -, Civ.C.). i. C�{ECK 31.01 i PLAN CHECKING FEE CHANGE .00 Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the above TOTAL FEE `, B d 0000-0001 9/10/90 information is correct.I agree to comply with all County ordinances ,. and State laws regulating Electrical wiring, and hereby authorize i 2789 1 AM 99 16 representatives of this County to enter upon the above-mentioned - property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date