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Home My Public Portal About9461 OLIVE ST_Electrical__ • WORKERS'COMPENSATION DECLARATION jCE-806G 10/81 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, or a'certificate o!^rkers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES, BUILDING AND.SAFETY copy thereof(Sec.3800,Lab.C.) Policy No. Company 4 FOR APPLICANT TO FILL IN JOB ❑ •Certified copy.is hereby furnished. EACH NO. FEE ADDRESS (p J y New Residential Bldgs.&Pools LOCALITY ❑ Certified copy is filed with the county building inspection 1 1 &2-Family,Sq.Ft. $ _ $ department. Multi-famil Sq.Ft. NEAREST 7� ' � Residential Swimming Pools CROSS.ST. U Ud Date Applicant OWNER OR 11 n, er s FIRM NAME, v '�/V a l CERTIFICATE OF EXEMPTION FROM WORKERS' , MAIL Outlets:Rec—Light_Sw.— COMPENSATION INSURANCE ; ADDRESS (This section need not be completed If the work involved by the First 20 CITYTel.No. I permit is for one,hundred dollars($100)or less.) Total No. Additional I certify that.in the performance of the work for which this permit PLAN CHECK is issued,J shall not employ any pers n in any manner so as to APPLICANT become subject to:the Workers'Comp atio LLAO Lighting Fixtures, First 20 ADDRESS )qTotal IVo. Additional' CITY Tel..No. Date r V APPlicant NOTICE TO APPLICANT: If, after "making this Certificate 'of Fixed Appliances Not Over 1 HP PERMIT , Exemption,you should become subject to the Workers'Compensation 1 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.. Top — FAU W.H. CITY Tel.No. LICENSED.CONTRACTORS DECLARATION Hood•_. Fan _ Other_ I'hereby affirm that.1 am licensed under provisions of Chapter 9 LICENSE OR (commencing with Section 7000)of Division 3 of the Business and Disp. ._ Room Air Cond. Class: I REG.NUMBER Professions'Code,and my license is in full force and effect. DISTRICT NO. PROCESS Y ' Power Apparatus&Large Appliances , / I Size&Type HP,KW,KVA,'or KVAR �• O G 0 License Number. Lic.Class 1. Up to-1 Inc[. FINAL 0 Confrabtor Date ' Over•1 to 10:In _ cl.. DATE ^__-,.VALIDATIO �_ v.� ` Over 10 to 50 Incl. ,FINAL r �� ;° ❑ I am exempt under'Sec. Over 60 to 100 Inc. BYf• ITL My /V29W BAP.C.for this reason I Over 100 dJ Services,Swbd.,MCC&Panelboards i I.)� L '•�n ".� Date:' 0-200 Amp.Under 600 Vf�^• ram + :,.Signature I 201 - 1000 Amp.Under 600 V `�ttt•'4 ❑ Over 1000 Amp.or Over 600 V CHNNut ° _t Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power.Pole&Appurtenances ' HOME OWNER-BUILDER DECLARATION } Sign with One Branch Circuit 1 12121„-0001 3/14•/89. I hereby affirm that I am ekempt.from the Contractor's'License Law Additional Sign Branch Circuits I + n58`47. for the following reason(Section 7031.5,Business and Professions 1 13 2 2 AM ° Code): Misc.Conduits&Conductors 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 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) S Civ.C.). i I PLAN CHECKING FEE Lender's Name j PERMIT ISSUING FEE Lender's Address i I certify'that I have feed this application and state that the above ' TOTAL FEE , information is correct.I agree to comply with all County ordinances 1 and State laws regulating Electrical wiring, and hereby authorize re sentat)ves f thi County to enter upon the.above-mentioned j erty r in c' n purpo es. C + SEE REVERSE FOR EXPLANATORY LANGUAGE S' nature of Per ittee: Date i r. Wh. RKERS'COMPENSATIOI�DECLARATION 76A663 °/e, APPLICATION FOR ELECTRICAL PERMIT that I have a certificate of"consent.to self insure, CE-Bo6G of Workers'Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY lu' copy. thereof(Sea 3800,Lab.GJ, Policy No. " Company FOR APPLICANT TO,FILL IN JOB ❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS (�j O c New Residential Bldgs.&Pools ❑ copy Is filed with the county building inspection $ — $. LOCALITY&2-Family,Sq.Ft. be- Certified department. Multi-family Sq.Ft. NEAREST Residential Swimming Pools. CROSS ST. Date Applicant OWNER OR FIRM NAME M2 61a, CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Re Light Sw. MAIL COMPENSATION INSURANCE. � 5 ADDRESS C (This section need not be completed if the work involved by the First 20 Total No. Additional CITY Tel.No: 'L permit is for one hundred dollars($100)or less.) - I certify that in the performance of the work for which this pe..rmit PLAN CHECK s.issued, I shall not employ. a APPLICANT iany person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures 2 7 First 20 ADDRESS Additional Total No. CITY Tel.No: Date Applicant Fixed Appliances Not Over 1HP' PERMIT NOTICE TO APPLICANT: If; after making this Certificate of Exemption,you should become subject to the Workers'Compensation Range_ Heater U/after APPLICANT provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer t7 W.M._ ADDRESS provisions or this permit shall be deemed revoked:. Top FAU. W.H. _ CITY Tel.No. LICENSED CONTRACTORS.DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under,provisions of Chapter 9 Disp. Room Air Cond. 04 EGNSE OR Class. (commencing with Section 7000),of Division 3.of the Business and Professions Code,and my license is in full force-and effect. DISTRICT NO. P ESSE B Power Apparatus&'Large Appliances , r++ Size&Type HP,KW,KVA,or KVAR of License Number Lic.Class Up to'1 Incl. FINAL Over 1 to 1.0 Incl, DATE � ^ � VALIDATION. C Contractor Date Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY W Over 1000. BAP.C.,for this reason N Services,Swbd.. anelboards Date: -200 Amp.Under 800 ,r Signature 201 - 1000 Amp:Under 600 V + x^ Over 1000 Amp.or Over 600'V ❑ Exemption for Reg.Maint.Elect. "" SINGLE FAMILY Temp.Power Pole&Appurtenances r T- HOME OWNER-BUILDER DECLARATION Sign with One Branch-Circuit ACCT-0 I hereby affirm that I am exempt from the Contractor's License Law h Ci B Si Sign rancrouits for the following reason(Section 7031.5,Business and Professions Additional. 3M7 .67.O ' Code): 1 ITM - Misc.Conduits&Conductors - - I,as owner of the property,will do the work and the structure. _ wig not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) v► 1OTA- 67 C30 and Professions Code). aEcK. 67.00 CONSTRUCTION LENDING AGENCY ty�pl I hereby affirm that there is a construction lending agency for the vfteu�l�G performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total) _ ,- Civ.C.). PLAN.CHECKING FEE 9/ 6/89 Lender's Name 1 PERMIT ISSUING FEE ffn 1 AAM10133 Lender's Address 0 O I certify that I have read this application and state that the.above TOTAL FEE VV 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 inspeation purpo SEE REVERSE FOR EXPLANATORY LANGUAGE, Sig�liof Permitte Date