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Home My Public Portal About5744 PRIMROSE AVE_Electrical__ WORKERS'COMPENSATION DECLARATION �.� +B'CE-806G (2.80)%k APPLICATION FOR ELECTRICAL PERMIT - 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'Co"rnpensation Insurance;or 1, , a certified copy thereof(Sec:3800,Lab.C.) 224110 aC1f1C National FOR APPLICANT TO FILL IN JOB Policy Na! Compan EACH NO. FEE ADDRESS �� .411!54 AR New Residential Bldgs.&Pools O Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY �y e! ® Multi-family Sq. Ft. — NEAREST , Certified copy is filled wiVthebuildi inspection CROSS S'1' department. Residential Swimming Popp OWNER OR / rrt /rte` FIRM NAME Date Applicant Outlets: Rec.aLightik Sw.� fir, MAILr7 4W . ' First 20 ADDRESS CERTIFICATE OF EXEMPTION F O ORKERS' Total No. Additional ITY Tel No. COMPENSATION INSU CE 4 /! D PLAN CHECK Al 9 a 4�4APPLICANT (This section need' not be completed if the. work involved Lighting Fixtures First.20 0 0 0 by, the permit is For one hundred"dollars ($100) or less.) ADDRESS Total No. Additionalcc I certify that in the performance of the.work for which thisCITY Tel No. 0 Fixed Appliances Not Over 1 HP permit is issued, I shall not employ y erson in any manner PERMIT so as to become subject to the Wo er omp tion Laws. Range_Heater D.W. _ APPLICANT' Ge & So Electric w Oven _ Dryer W.M._ ADDRESS N 53Y •S. Atlantic Blvd. Top _FAU -TW.H. Z Date Applicant • CITYMontere P�=�Tel No. 283-6.317 \ Hood _ Fan _Other— NOTICE TO APPLICANT• f, after m i this Certificate of Disp. _Room A(r Cond— LICENSE OR Exemption, you should become sub! ct to the Workers', REG.NUMBER 248057 Class C10 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. � Sized Type,HP,KW,KVA,or KVAR Up to 1 Incl. ' FINAL LICENSED CONTRACTORS DECLARATION — -Over.'1 to 10 Incl, i DATE °�� v � VALIDATION Over 10 to 50 Incl. // I hereby affirm that I am licensed under provisions of ChapterOver 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 \1 ' effect. Services , License Number#248057 Lic:Class C100-200 Amp,Under 600 V G f&A 201-1000 Amp.Under Contractor, ate Over 1000 Amp.or Overr 600 V ' HOME 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).: Misc.Conduits&Conductor's I, as owner of the property, will do the work and the ,Other(See Complete Fee Schedule)— " 5 f?G structure is not intended or offered for sale (Section 7044,Business and Professions Code). �' 0 0 0 0 o2 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 2,0 o 4 7 5'() for the performance of the"workfor which this permit is TERMIT FEE (Sub-Total) issued(Sec.3097,Civ.C.). 1 I "a n u 4 7 3(� Lender's Name PLAN CHECKING FEE (One-Fourth Peemit•Fee) t 2.,28-8?_ Lender's Address PERMIT'ISSUING FEE I certify that I have read this application and state-that the- 'TOTAL FEE above infor. tion is correct. agree to comply with all County ordinances nd tate laws' egulating Electrical wiring, and hereby a or' epresent es of this unty to enter upon the abo - coned prop y for ins on purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE i 2- Signature o er tee Ilate I /'p WORKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT CE-806 I hereby affirm that I have a certificate of consent to self I COUNTY OF LOS ANGELE$� BUILDING AND SAFETY insure,or a certificate of Workers'Compensation Insurance,or l` y a certified copy thereof(Sec.3800,Lab.C.) I FOR APPLICANT TO FILL IN JOB �y Policy No. Company ADDRESS /6wt�S E' New Residential Bldgs.&Pools EACH NO. FEE Certified copy is hereby furnished. 1 &2-Family,Sq.Ft. $ $ LOCALITY Certified copy is filed with the count Multi-family Sq. Ft. NEAREST y buildin g inspection � CROSS ST department. Residential Swimming Pools OWNER OR ,r FIRM NAMEC��/ �fS i�C` Lr /�•Cl^ Date Applicant Outlets: Rec.—Light Sw. MAIL / �j6s1 /�8 L•'C i First 20 ADDRESS ' CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. COMPENSATION INSURANCE PLAN CHECK a} APPLICANT O (This section need not be completed if the work involved Lighting Fixtures First 20 V by the permit is for one hundred dollars ($100) or less.) Additional ADDRESS _ Total No. tr I certify that in the performance of the work for which thisFixed Appliances Not Over 1 HP CITY Tel No. O permit is issued, I shall not employ any person in any manner PERMIT so as to become subject to the-Workers'Compensation Laws. Range_Heater D.W._ APPLICANT W Oven _. Dryer_W.M._ ADDRESS Vaj Date Applicant Top _ FAU _W.H.._ Z Hood Fan _Other_ CITY Tel No. NOTICE TO APPLICANT: If, after making this Certificate of Disp. —Room Air Cond.— 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 NO. P ED BY with comply with such provisions or this permit shall be deemed revoked. Size,&Type HP,KW,KVA,or KVAR � Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE LICENSED CONTRACTORS DECLARATION — T �� VALIDATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter i Over 50 to 100 Inc. FINAL 9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 ness and Professions Code, and my license is in full force and effect. jr2011rviceyl f / 0-200 Amp.Under 600 License Number Lic.Class �' -16ifAmp.Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtepances 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): - 4.4 4. 1 P Misc.Conduits&Conductors 1, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— 0 0 0 0 0 structure is not intended or offered for sale (Section 7044,Business and Professions Code). I . CONSTRUCTION LENDING AGENCY 2 ° ° 1 9.50 I hereby affirm that there is a construction lending agency 0 c 0 1 9.5 0 cT` for the performance of the work for which this permit is PERMIT FEE (Sub-Total) issued(Sec.3097,civ.C.). 0 3 1 5=8 1 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's Address PERMIT ISSUING FEE I certify that have read th'Fggulating pplication and state that the TOTAL FEE above infor tion is correctree to comply with all County ordina a and tate law Electrical wiring, and ' her y hori repre ives of is County to enter upon I 1 t e-me ned r rty for pection purpose . SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Da