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Home My Public Portal About9217 OLIVE ST_Electrical__ WORKERS'COMPENSATION DECLARATION I,6A663 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self E 806G insure, ora 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 n Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS '- Certified copy is filed with the co ty building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY I, tion ep tment. Multi-family Sq. Ft.. — "NEAREST Residential Swimming Pools CROSS ST. ' Date Applican ' OWNER OR FIRM NAME RTI ICATE OF EXENIPTI FROM WORKERS' Outlets:Rec Light Sw._ 'MAIL COMPENSATION NSURANCE ADDRESS V i (This section need not be completed If the work Involved y First 20 Total No. Additional CITY b the permit Is for one hundred dollars($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued,1 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. i Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of 1 APPLICANT YY op 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 3 s' rl b r f f with comply with. such provisions or this permit shall be Top _.FAU _WH deemed revoked. CITY Tel. No. Q 7 Hood _ Fan _(941+15r� E L - 7 LICENSED CONTRACTORS DECLARATION ,� LICENSE OR Disp. _ Room Air Cond. — J .A 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 DISTRICT NO. PROCE ED BY and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances IL Size&Type HP, KW, KVA,,or KVAR (',y O License NumberGS`ilp( Lip. Class Q FINAL l•Jp to 1 Incl'. Over 1 to 10 Incl. DATE /Z � VALIDATION O Contractor Date Over 10 to 50 Incl. V ❑ FINAL I a exempt under Sec. Over 50 to 100 Inc. BY 9M B.&P.C.for this reason Over 100 Z Date: Services, Swbd., MCC&Panelboards 0 -200 Amp, Under 600 V Signature 201 - 1000 Amp. Und6r 600 V Over 1000 Amp, or Over 600 V Exemption for Reg. Maint. Elect. 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 Additional Sign Branch Circuits Law for•the following reason (Section 7031.5, Business and I Professions Code): ❑ I, as owner of the property, will do the work and the Misc. Conduits&.Conductors ;E 7 6 IL 1 A structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ , t, 7044, Business and Professions.Code). ? o o`o o. 0 2 CONSTRUCTION LENDING AGENCY 2 - 32,50 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) Q 0 p o 3 2 5 0 t=i (Sec. 3097,.Civ. C.). l 1. 1 7-e2 PLAN CHECKING FEE Lend'er's Name PERMIT ISSUING FEE 0 . Lender's Address . I certify that I have reod this application and state that the TOTAL FEE 1301. 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 ' the ve-mentione roperty for inspection pur oses. i � SEE REVERSE FOR EXPLANATORY LANGUAGE , Signature of Permittee Vote u WORKERS',ave.a COMPENSATION of consent 78-88$ 10/87 APPLICATION FOR ELECTRICAL PERMIT 'i preiet r ffirm that I have a certificate of consent to self insure, CE-806a or a certificate.of Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY 9opy thereof(Sea 3800,Lab..C.) Policy No.. Company FOR APPLICANT TO FILL IN JOB �:7 9p2 j� � �G£d ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS sj ❑ 1 &2-Family,Sq.Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. — Residential Swimming Pools CROSS ST... Date Applicanto. NER OR CERTIFICATE OF EXEMPTION FROM WORKERS' � � � `� MAIL NAME Outlets Rea Light Sw.— ��1'7 �" ' 0a&V sr. COMPENSATION INSURANCE ADDRESS (This section need-noUbe completed if the work involved by the First 20 permit is for one hundred dollars($100)or less.) Total.No. Additional CITY �SAVLrr e-1 y Tel.Ncx�o ��l�•' 1 certify that in the performance of the work for which this permit PLAN CHECK APPLICANT is issued, I,shall not employ any person in any manner so as to become subject to.the Workers'Compensation taws. Lighting Fixture First 20 ADDRESS 6 Total No. Additional CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE- O APPLICANT., if, after makin is C ficate of APPLICANT Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D...W. provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M:_ ADDRESS provisions or this permit shall be deemed revoked. Too _ FAU _ W.H. LICENSED CONTRACTORS DECLARATION �.. Hood — Fan _ Other_ CITY Tel.No. _ .I hereby affirm that I.am licensedunder provisions of Chapter 9 Disp. Rdom Air Cond. LICENSE OR -� (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER Class Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. S PROCESSED BIC1.y Size&Type HP,KW KVA,or KVAR License Number Lic.Class Up to 1 Incl. FINAL Contractor Date Over 1 to 10 Incl.• DATE VALIDATION 0 Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY „W BAP.C.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 ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole&Appurtenances HOME.OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the C.ontractWs License Law Additional Sign Branch Circuits for the following reason(Section 7031.5,,Business'and Professions ;2 9 5 2 O A ' Code): Misc.Conduits&Conductors 0 0 0 0 0'2 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). CONSTRUCTION LENDING'AGENCY 16 0 21.O O• I hereby affirm that there is a construction lending agency,for the � 30:performance of the work for which.this permit is issued(Sec.3097, PERMIT FEE (Sub Total). 10,10 o 0 0 2 1,'0 O y Civ.C.). PLAN CHECKING FEE `*'� O O;O O"8 8 Lender's.Name PERMIT ISSUING FEE p�I Lender's.Address I certify that I have read this application and state that the above TOTAL FEE .. information`is'correct.I agree to comply wifh all County ordinances , and State laws regulating Electrical winning, and hereby authorize representatives of this County to enter upon.the above-mentioned Property for inspection pur SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pe ' ate .ERS'COMPENSATION DECLARATION CEAaca . 10/81 APPLICATION FOR ELECTRICAL PERMIT •' CEr808G 19�ere.y aff . hat I have a certificate of consent to self insure,, or a certific2 of.Wor.ers'Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof Sec.380%,L'ab Policy No. Company– S�2A7� FOR APPLICANT TO FILL IN JOB A ❑ Certified c by furnished. ,, EACH NO. FEE ADDRESS /217 �+ 40L IVAE rf New Residential Bldgs.&Pools ❑ 1 &2-Family,Sq.Ft. $ — LOCALITY SOLE Certified copy is filed with the county building. inspection NEAREST dep rtme t: Multi-family Sq.Ft. coo CROSS ST. SN(:Z4/V/7As Date/ Applicant ResidetiaSwimming Pools' OWNER'OR Z FIRM NAME /A.B JW CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec -2--Light�—/ Sw. MAIL COMPENSATION INSURANCE AA9 ��Cp ADDRESS /,o (�� '1114MY RIO, (This section,need not.be completed If the work Involved by the First 20 3 Total.No. 45 Additional CITY fW4W f Tel.No:Rg--Mp�1o3 permit is for one hundred dollars($100)or less.) PLAN CHECK��bb 9 �`' I.certify that in the performance of the work for which this permit APPLICANT /7p 1V7?e4CMKS is 'issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws.. Lighting Fixtures First 20 ADDRESS 3.r /$ Additional' ' Total No, r� CITY Tel.No�B�_ Date Applicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If,, after making this Certificate of 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 S;q–/8 V1,5771 1-1.411,45y RP, provisions or this.permit shall be deemed revoked. Top _ FAU __W.H. _ Q CITY Q s Tel.No.f/j?7/,#.9gj LICENSED CONTRACTORS.'DECLARATION Hood'_ Fan Other_" I hereby affirm that I am licensed'under provisions of Chapter 9 LICENSE OR (commencing with Section 7000)of Division 3 of•the'Business and Disp. — Room Air Cond.. REG:NUMBER Q�� Class. Professions Code,and my license is in full force,and effect. Power Apparatus&Large Appliances DISTRICT NO. SED BY Size&Type FIP;KW,KVA,or KVAR License Number� /�24�Lic.Class.. Up to 1 Incl FINAL Contractor bate �l Z Over 1 to 10 Incl. DATE 77 /�` VALIDATION Q Over 10 to 50 Incl. FINAL, ❑ I am.exempt under Sec.. Over 50 to 100 Inc. BY P 2 W BAP.C.for,this reason Over.100 ,1 ACCT•Q Dater Services,Swbd.,MCC&PAnelboards ® 3303 11'. 5. 0-200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V 1'ITEMS ❑ Over 1000 Amp.or Over 600 V Exemption for Reg..Maiint.Elect. TOTAL 11-5 o 55 SINGLE FAMILY Temp.Power Pole&Appurtenances CHECK 115.55 HOMEOWNER-BUILDER DECLARATION Sign,with One Branch Circuit I hereby affirm that 1 am exempt from the Contractor's License Law CHANGE ,QO for the following reason(Section 7031.6,Business and Professions Additional Sign Branch Circuits Code): 0 I,as owner of the property,will do the work and the structure 0000 Misc.Conduits a Conductors -11/27/95 -Is not intended or offered for sale (Section 7044, Business Other(See Complete.Fee Schedule) and Professions Code): 3436 1 R112o09 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 (Sub Total)' Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE O Lender's Address I 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 Is we regulating Electrical wiring, and hereby authorize representatives f this unty to enter upon the above-mentioned property f pection ur ses. SEE REVERSE FOR EXPLANATORY LANGUAGE 6l "VA5 Signature of Permittee Date