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HomeMy Public PortalAbout9135 OLEMA ST_Electrical__ WORKERS'COMPENSATIONDECLARATION CE-806 . APPLICATION FOR ELECTRICAL PERMIT ,0,M CE 806G (2.80) 1 I hereby affirm that I have a certificate of consent to self 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or i a certified copy thereof(Sec.3800,Lab.C.) Policy No.- -0ll�f �t1�V�"` 1 FOR APPLICANT TO FILL IN /- New Residential Bldgs.&Pools EACH NO. ADDRESS FEE Certified copy is hereby furnished. I 1 &2-Family,Sq.Ft. — $ 1 LOCALITY C'7 I Multi-family Sq. Ft.'' — NEAREST Certified copy is filed with the county building inspection Residential Swimming'Pools CROSS ST departmen pt. /7,�f OWNER OR � 0 �.4-wSo Date - -fJ Applican+al., '`���'��L� `r��' " FIRM NAME Outlets: Rec.—Light rst ADDRESS First 20 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE Total No. Additional CITY LG Qom¢ Tel No. 206- $]T�/ a PLAN CHECK O APPLICANT (This sectionneed not be completed if the work involved s V �Li hting.Fixtures First 20 by the permit is for one hundred dollars ($100) or less.) ;� Total No. Additional ADDRESS O I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. permit is issued;I shall not employ any person in any manner PERMIT p/ / W so as to become subject to the Workers'Compensation Laws. " Range_Heater D.W._ APPLICANT L/T', /Mg"�f L u' Oven _ Dryer—W.M._- ADDRESS . � b � �,1j G 4a Z Top _ FAU .-W.H..— Date Applicant ( CITY jv��/S Tel No. Hood Fan —Other_ NOTICE TO APPLICANT:-If,.after making this Certificate of I. Disp. _Room Air Cond,_ . LICENSE OR [� Exemption, you should become subject to the Workers' REG.NUMBER 9 20�0�10 Class /C C) Compensationprovisions of the Labor Code,you must forth- 'Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY with comply with,such provisions or this permit shall beTy. HP,KW,KVA,or,KVAR deemed.revoked. / Z 6-W, II Up to 1. Incl. FINAL ' Over 1 to 10 incl. DATE �r LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. VALIDATION I hereby affirm that I am licensed under provisions.of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000)of Division 3 of the Busi- II Over 100 BY ness and Professibns.Code,and my license is in full force and effect. 'Services Z License Number �f%O Lic.Class My Cl`' 0-200 Amp.Under 600 V ,,yy ��//• 201-1000.Amp.Under 600 V Contracto64184� WW-P-0fDate Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole,&Appurtenances 1 I hereby affirm •that I am exempt from the Contractor's )Sign with One Branch Circuit p 2 C p License Law for the following reason (Section 7031.5, Buss• yAdditional Sign Branch Circuits # 0 0 0 0 0 2 ness and Professions Code): Misc.Conduits&Conductors 2 0 0 2 j c Q ' El I, as owner of the property, will do the.work and the Other(See Complete Fee Schedule)— structure is not intended or offered for sale (Section '7044, ' •7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 1.2 - n for the performance of the work for which this permit is PERMIT FEE (Sub-Total). >-7 O issued(Sec.3097,Civ.C.). Lender's NamPLANCHECKING FEE (One-Fourth Permit Fee) Lender's Address ( PERMIT ISSUING FEE 7 \ I certify that I have.,read this application and state that the `1`O.TAL FEE above information is correct.I-agree to comply with.all County ordinances and State laws regulating Electrical wiring, andI it j C' W- S-1.6 hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE"REVERSE FOR EXPLANATORY LANGUAGE rW g 2 fl0 Signature of Permittee Date ' WORKERS'COMPENSATION DECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL- PERMIT I hereby affirm that I have a certificate of"cdnseneto self • COUNTY OF LOS ANGELES BUILDING AND SAFETY insure,or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec.3800,Lab.C.) FOR APPLICANT TO FILL IN JOB �- Policy No. Company New Residential Bldgs.&Pools EACH NO. FEE ADDRESS i 3, lVieema S n' Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — S LOCALITY _ Ca q. , O Multi-family Sq..Ft. NEAREST ' Certified copy is filed with the county building inspection Residential Swimming Pools department. FOWN NAME Date Applicant Outlets: ReclLight C _Sw.-A,�na �G© MAIL First 20 ADDRESS CERTIFICATE 01:EXEMPTION FROM WORKERS' Total No. 30,� Additional O 101r CITY Tel No. } COMPENSATION INSURANCE PLAN CHECK p, APPLICANT O (This section need not be completed if the work involved j gIf ZIP Fixtures First 20 F n htig iU by the permit is for one hundred dollars ($100) or less.) LigAdditional ADDRESS Total No. I certify that in the performanceof the work for which thisCITY Tel No'. 0 Fixed Appliances Not Over 1 HP ' permit is issued, I shall not employ any person in any-manner PERMIT so as to become subject to the Workers'Compensation.Laws.k Range_Heater D.W. 'APPLICANT /) ^ Oven Dryer_W.M._ ADDRESS � Date 4-1 -- '-Applicant Y� a1-+aW�/ , Top FAU W.H. h,� �� , �. . Hood .� Fan �Other 1� CITY Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Condi_ LICENSE OR Exemption, you should become subject to the Workers' REG.NUMBER Class Compensation provisions of the Labor-Code, you must forth- Power Apparatus&Large Appliances DISTRICT N PROCESSED BY with comply with such provisions or this permit,shall be �' deemed revoked. r Size&Type HP,KW,KVA,•or KV.AR rf- •Up.to 1 Incl.. FINAL LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE, -2VALIDATION Over 1'0 to 50 Incl. . I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL 9 (commencing with'Section 7000)of Division 3 of the Busi- Over 100 BY ness and Professions.Code, and my license is in full force and effect. Services License Number. Lic.'Class 0-200 Amp.Under 600 V 201-1.000 Amp.Under 600 V _ Contractor Date Over 1000 Amp.or Over 600 V I40ME.OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit License. Law for the following reason (Section 7031.5, Busi- Additional.Sign Branch Circuits ness and Professions Code): Mise.Conduits&Conductors E] I,•as owner of the property,will do the work and the Other(See Complete Fee Schedule)— structure is not intended or,offered for sale (Section 7044,Business and Professions Code). 6 4 1.3 A CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency ` 0 0 0 0,0 .2 'for the performance of the work for which this permit is PERMIT FEE (Sub-Total) �d issued(Sec.3097,Civ.C.). 2 0 0 49.30 Lender's Name 1 PLAN CHECKING FEE (One-Fourth Permit Fee) ' „ 9 X i - � Lender's Address �. PERMIT ISSUING FEE 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 1 hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE CL Signature of Permittee Date