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Home My Public Portal About5221 SANTA ANITA AVE_Electrical__ I WORKERS'COMPENSATION DECLAMATION 7UAbud 10/81 CE-808APPLICATION FOR ELECTRICAL PERMIT {� L1 I hereby affirm that I rive a•cehificate'of con8ent to'self insure,. CE -808G a certificate of Workers' Compensation Insurance, or a certified i COUNTY OF LOS ANGELES BUILDING AND SAFETY cbpy the f(S",eby ab.C.) I!/� //1, �J1_ Policy I4o. Company FOR APPLICANT TO FILL IN J-ODDRESS %/�f N I !T r 77* Certified furnish New Residential Bldgs.&Pools EACH NO. FEE Certified copy is filed with oun b i g in pection 1 &2-Family,Sq.Ft. $ — $ LOCALITY de art ant. Multi-family Sq.Ft. — NEAREST CROSS ST. rate Applicant Residential Swimming Pools OWNER OR Appliiiiii FIRM NAME CERTIFICATE OF EXEMPTION FROM WORK MAIL COMPENSATION INSURANCE Outlets:Rec. Light Sw. ADDRESS M® �—v (This section need not a completed If the work i volved by the First 20 permit is for one hundre dollars($100)or less.) Total No. Additional CITY el.No � 6� PLAN I certify that in the perfor nce of the work for which this permit APPLICANT CFIECK r - is issued, I shall not emplo any person in any manner so as to �� become subject to the Worke 'Compensation Laws. Lighting Fixtures First 20 ADDRESS7 A0 Additional Total No. CITY t//"—^ Tel. �' Date Applica t Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, a r making this Certificate of PERMIT Exemption,you should become subje t to the Workers'Compensation Range— Heater D.W. APPLICANT provisions of the Labor Code,you m t forthwith comply with such Oven — Dryer k W.M.— ADDRESS provisions or this permit shall be deem revoked. Top _ FAU —, W.H. — CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan Other- 1 hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR Disp. — Room Air Cond. REG.NUMBERrl Class. (commencing with Section 7000)of Division 3 of the Business and Professions Code,and my license is in full force and effect. Poweir Apparatus&Large Appliances DISTRICT NO. PR CES B Size&Type HP,KW,KVA,or KVAR U License Numhr Lic.Class II Up to 1 Incl. FINAL �y / J�Over 1 to 10 Incl. DATE VALIDATION Q Contractor 0, Date Over 10 to 50 Incl. 0 FINAL V/ ❑ I am exempt under Sec. Over 50 to 100 Inc. BY W Over 100 n" B.&P.C.for this re Z D 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. SIN LE FAMILY Temp..Power Pole&Appurtenances n HOME OWNER- ILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exem t from the Contractor's License Law s for the following reason(Sectio 7031.5,Business and Professions Additional Sign Branch Circuits ANT e� Code): ^3137 36 e LI3 Misch Conduits&Conductors ITEMS ❑ I,as owner of the property, Ido the work and the structure Othe See Complete Fee Schedule is not intended or offered for ale (Section 7044, Business f( ) — ® _ and Professions Code). I OTAL 36 o 60 CONSTRUCTION LENDIN GENCY !`tG1��i I hereby affirm that there is a constructio lending agency for the performance of the work for which this per 't is issued(Sec.3097, PERMIT FEE (Sub Total) _3 CHANGE00 Civ.C.). i PLAT CHECKING FEE Lender's Name II PERMIT ISSUING FEE Lender's Address 0625 1 AM 9 o ir2 1 certify that I have read this application and state t at the above TOTAL FEE ads is c r�ect.I ag a to comply with all Count ordinances Is reg ng Electrical wiring, and hereb authorize ti of iso my t enter upon the above- entioned r sp ion pu ose . SEE REVERSE FOR EXPLANATORY LANGUAGE of mi Date WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O hM affirm that I have a certificate of consent to.self 7MM3 • *ensu ? or a certificate of Workers'Compensation Insurai ice, CE-606G COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a ctrtifi d copy thereof(Sec. 3800, Lqb. C.) } • Polisx-No r ompany- �_ / ! FOR APPLICANT TO FILL IN JOB �-7 ❑ t� , er' ied copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ! ADDRESS / G- P Certified copy is filed with the c nt buildi i s - 1 &2-Family, Sq. Ft. $ _ $ LOCALITY .ion departure Multi-family Sq. Ft. NEAREST OWNER T.CROSS ST. Date D Applicant Residential Swimming Pools / FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKE Outlets: Rec Light First 20 Sw._ I MAIL C COMPENSATION INSURANCE i ADDRESS OVf (This section need not be completed if the work involved by Total No. Additional CITY ` G(;'(/ Tel. No.287. D('' the permit is for one hundred dollars($100)or less.) HECK I certify that in the perfNtmance of the work for which'this PLAN C APPLICANT permit is issued, I shall not�employ any person in any manner so as to become subject toithe Workers'Compensation Laws. Lighting Fixtures First 20 ( ADDRESS 1_ Z,- 0 Z S, _ Additional c— Date Applicant— — Total No. 6 CITY p fly�� Tel No. �7�2S Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION � / d Exemption, you should b come subject to the Workers' Range — Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— I ADDRESS with comply with such pro isions or this permit shall be Top — FAU —W.H. — deemed revoked. CITY Tel. No. Hood — Fan —Other— LICENSED CONTRA TORS DECLARATION LICENSE OR r Disp. _ Room Air Cond. — 7 � Class. I hereby affirm that I am license rider provisions of ChapTer 9 REG. NUMBER -� (commencing with Section 7000 f Division 3 of the Business Power Apparatus&Large Appliances I DISTRICT NO. P CESSED BY a and Professions Code,and my license is in full force and effect, �� O •��f Size&Type HP, KW, KVA, or KVAR �D ! �- License Num fv�✓�� Lic. Class Up to 1 Incl. FINAL ccV 5 Over 1 to 10 Incl.' DATE r (� VALIDATION Contractor Date ) Over 10 to 50 Incl. O ❑ FINAL U I am xempt under Se Over 50 to 100 Inc. BY W B.&P.C. for this r son i I Over 100 i a Services, Swbd., MCC&Panelboards ® Z /1 / D e:i Z 0-200 Amp. Under 600 V Signature r 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. .aint. Elect. SIN LE FAMILY Temp. Power Pole&Appurtenances HOME OWNER- UILDER DE LARATION AC-0.� .s I hereby affirm that I am ex mpt from the Contractor's License Sign with One Branch Circuit FI= ■sr Law for the following reas n (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): Misc. Conduits&Conductors ❑ I, as owner of the pro erty, will do the work and the _ structure is not intends or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ TOTAL o 00 Business and Profession Code . ` +yie L I CONSTRUCTION ENDING AGENCY I hereby affirm that there is a onstruction lending agency for1 �1w� =1= the performance of the work r which this permit is issued PERMIT FEE (Sub-Total) Q (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 15 1 00 a j2Ajy 'r:272 Lender's Address � I certify that I have read this application analstate that the TOTAL FEE / above information is pe to comply with all County i ofdinances and St a law egu ting Electrical wiring, and ereby thorize res t ive of is County to enter upon I bo a-ment' ned p rt y r' spectipurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE � ature of P e Dote