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Home My Public Portal About5710 PRIMROSE AVE_Electrical__ I WORKERS'COMPENSATIONDECLARATION 176AS63 CE-8066G (2-80) APPLICATION FOR ELECTRICAL. PERMIT ' CE- I hereby affirm.that I have a certificate of consent to 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.) i FOR APPLICANT TO FILL IN JOB /`l Policy No. Company ADDRESS d New Residential Bldgs.&Pools EACH' No. FEE Certified copy is hereby furnished. 1 &2-Family,Sq.Ft. $ — $ LOCALITY 01 Multi-family Sq. Ft. NEAREST — Certified copy is filed with the county building inspection Residential Swimming Pools CROSS ST04 department. OWNER OR FIRM NAME Date Applicant Outlets: Rec.____Light Sw. ADDRESS / First 20 ERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. COMPENSATION INSURANCE PLAN CHEC a (This('section need not be completed if the work involved APPLICANT vQ by the, permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS Total No. Additional O I certify that in the performance of the work for which. this Fixed Appliances Not Over 1 HP CITY Tel No. H permit is issued, I shall not.employ any person in any manner PERMIT W so as to llecome subject to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANT a ` Oven _ Dryer_W.M._ ADDRESS CO) Dat o Applica Top _FAU W.H. Hood —Fan _Other. CITY Tel N to TO APPLICANT: If,after making this Certificate of Disp. _Room Air Contl:_ 6 '. 3 LICENSE OR �!v Exemption, you should become subject to the Workers' REG.NUMBE. Class Compensation provisions of the Labor Code,,you must forth- Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY with comply with -such provisions or this permit shall be ,deemed revoked. Size&Type,HP,KW,KVA,or KVAR /� O� I Up to 1 Incl. bd y ( Over 1 to 10 Incl. jFINAL 'LICENSED CONTRACTORS DECLARATION Over 10.t0 50 incl. DATE 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- Over 100 BY ness and Professions..Code, and my license is in full force and effect.. ' Services License.Num e! �� lie.Class0-200 Amp.Under 600 V `"' ¢ ' 201-1000 Amp.Under 600 V Contract ate ��O Over 1000 Amp.or Over 600 V ' I , HOME OWNER-BUILDER D LARATION 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): 0 1 9.0 A Misc.Conduits&Conductors 'ci 0 0 0 0 0 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). 2 ° 0 3 2 5.0 • CONSTRUCTION LENDING AGENCY , I hereby affirm that there is a construction lending agency o 0 o j j cZ for the performance of the work for which this permit.is . issued(Sec.3097,civ.C:). PERMIT FEE (Sub-Total) 0 h 1 5-81- Lender's Name, PLAN CHECKING FEE (One-Fourth Permit Fee) .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 ind State laws regulating Electrical wiring, and hereby authorize representati es of this County to enter upon ?theave- ntioned propertr i pection. urposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date) �/ NORKERS'COMPENSATION DECLARATION 76A60 L-0 � :icer affirm that J,have d certificate of consent to self CE-806G 10/81 APPLICATION FOR ELECTRICAL PERMIT rl Itsure;I8t•'a cert)ficate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a'certified-copy thereof(Sec. 3800, Lab. C.) i Policy No. Company FOR APPLICANT TO FILL IN JOB-' /O ❑ Certified copy is hereby furnished. New Residential Bldgs. &Pools`! EACH NO. FEE ADDRESS 1 &2-Family, q S Ft. $ = $ LOCALITY L Certified copy is filed,with the county building inspec- tion department. Multi-family Sq. Ft. NEAREST m CROSS ST: Residential Swimming Pools V Date Applicant OWNER OR / FIRM-NAME L 4 CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec tP Light 2- Sw.� ,MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work Involved by / First 20 Total NTel. No. the permit Is for one hundred dollars($100)or less.) o. `d Additional CITY I certifythat in the erformance'af the work for which this PLAN CHECK P APPLICANT permit 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 _ Total No.�_ Additional CITY Tel. No. Date pplicant Fixed Appliances Not Over 1 HP PERMIT / NOTICE TO APPLICANT: If, after making i ertificate of APPLICANT G L tL 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. — _ CITY Tel. No. 3 deemed,revoked. Hood Fan _Other_ /yj Cj� I LICENSED.CONTRACTORS.DECLARATION LICENS OR I hereby affirm that I a.m.licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Class.0 (commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCESSE and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances d Size&Type HP, KW, KVA, or KVAR• License Number Lic. Class FINAL / U Up to 1 Incl. C/1�., 09 Contractor Date — Over 1 to 10 Inc[. DATE VALIDAT N ❑ Over 10 to 50 Incl. FI I am exempt under Sec. Over 50 to 100 Inc. B L B.&P.C. for this reason Over 100 Date: Services, Swbd., MCC&Panelboards 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 FAMILY68 7.8'A HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I hereby affirm that I am exempt fSign with One.Branch Circuit # o 0 0 o 0 2rom the Contractor's License Additional Sign Branch Circuits Law. for the following reason (Section 7031.5, Business and Professions Code): J o -21.00 Misc.-Conduits&Conductors I, as owner of the property, will do the work.and the x structure is not intended or offered #or said (Section Other(See Complete Fee Schedule)_ ® o 0 0 2 1, 0 0 xt 7044, Business and Professions Code): CONSTRUCTION LENDING AGENCY i 6 2 i$7 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.,). PLAN CHECKING FEE Lender's.Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the ITOTAL FEE above,information is correct. 1 agree to comply with all County ordinances and'State laws regulating Electrical wiring, and hereby'authorize.representatives of this County to enter upon the a ove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature flee ' Date