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Home My Public Portal About5516-5518-5520-5522 SULTANA AVE_Electrical__ WORKERS COMPENSATION DECLARATION 76A8663 APPLICATION FOR ELECTRICAL PERMIT _ CE-806G E- 12 801 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES ' T BUILDING AND SAFETY insure or a certificate of Workers'Compensation Insurance or _ f B Ci�syNJ�cppY thereof mP^80 / Q/P / �LLf_E UY s FOR APPLICANT TO FILL IN JOB 5 D New Residential Bldgs &Poole EACH NO FEE ADDRESS J ❑ Certified copy is hereby furnished _ 1 &2-Famdy,Sq Ft $ — S LOCALITY .e Multi family So Ft Certified coDY u filed with the county budding mspecbo Residential Swimming Poole CROSS ST Q - dap /_en , g FIRM NAME /'' Data YJ Applicant Outlets Rec_Light Sw _ MAIL 9`0 r�l� must 20 oy CERTIFICATE OF EXEMPTION FROM WORKERS Total No AdditionalCITU •1 NoUZ T COMPENSATION INSURANCE PLAN 0E d (This sectbon need not be completed If the work Involved APPLICANT Q by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS IE Total No Addrtionel O 1 certify that'in the performance of the work for which this Fixed Appliances Not Over 1 HP - CITY, Tel No F permit u issued, 1 shall not employ any person In any manner PERMIT P W so as to become subject to the Workers'Compensation Laws -Range_ Heater_D W APPLICANT ✓ d Oven _ Dryer_-W M _ ADDRESS r Date Applicant Top _ FAU _W H Hood _ Fen _Other— CITU 0� Tel N04VH -S NOTICE TO APPLICANT If, after making this Certificate of Disp _ Room Air Condom C R //-'� Exemption, you should become subject to the Workers' REO NUMBER V Class Compensation provisions of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO PRO ESSP BV with comply with such provutom or this permit shall be Size&Type HP KW, KVA or KVA '�i deemed revoked I 'o Up to 1 Incl . S Over 1 to 10 Incl FINAL LICENSED CONTRACTORS DECLARATIONDATE VALIDATION Over 10 to 50 Incl 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-Hud BY Over 100 �-- ' nese and Professlom Code, and my license is in full force and effect Services r ?j (� 0 200 Amp Under 600 V �/✓zi License Number Lo: Cls � 201-10 Amp Under D r� i Contractor ate �� Over 100D 0 Amp or Overr 6 600 V HOME OWNER BUILDER DECLARATION Temp Power Pole& Appurtenances - I hereby affirm that 1 am exempt from the Contractor's Sign with One Branch Circuit ' License Law for the following reason (Section 7031 5, Bum Additional Sign Branch Circuits ness and Professions Code) �4 3 G 9 A Misc Conduits&Conductors ❑ I, as owner of the property wdo the work and the Other (See Complete Fee Schedule)— # • • • • • 2 structure is not intended or offered ered for sale (Section -_ 7044, Busmen and Professions Code) - 2'- • V2 O O CONSTRUCTION LENDING AGENCY - 1 hereby affirm that there is a construction lending agency , 2005 for the performance of the work for which this permit is ' issued(Sec 3097,Civ C) PERMIT FEE (Sub Total) _ Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 0306-81 Lender's Address PERMIT ISSUING FEE i I certify that I have read this application and state that the TOTAL FEE 'f above information is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authonze representatives of this County to enter upon the above�tioned roperly for impact nroDerty for impact n purppsn ' SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Signature of�rmrtte ,� Date t • WO*ERS'COMPENSATIONDECLARATION CE-86 APPLI TIO R ELECTRICAL PERMIT CE-8606G (2 SOI t I hereby affum,tbht 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) ' FOR APPLICANT TO FILL IN JOB Policy No ' Company New Residential Bldgs &Pools EACH NO FEE ADDRESS Certified copy is hereby furnished 1 &2 Famdy,Sq Ft $ — S LOCALITY, r� Certified copy a filed with the county budding inspection Multifamily Sq Ft CROSSST department Residential Swimming Poole OWNER OR FIRM NAME < Date Applicant Outlets Rec_Light Sw _ MAIL J first 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' 9114.9 F, Total No Additional CITTel No >.COMPENSATION INSURANCE PLAN CHECKa• (Thu section need not be completed if the work involved i APPLICANT by the permit u for one hundred dollars (5100) or less) Lighting Fixtures First 20 ADDRESScc ' Total No Additional cc I certify that in the performance of the work'for which this CITY - Tel No F permit is issued, I shall not employ any person in any manner ' Fixed Appliances Not Over 1 HP U PERMIT so as to become subject to the Workers Compensation Laws Range_ Heater_D W _ APPLICANT a ' ' Oven _ Dryer_W M _ ADD RE&S Z Date Applicant Tap _ FAU _W H _ 10 a� Hood _ Fen _Other_ CIT C Tel N NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ CEN Exemption, you should become subject to the Workers' REG NUMBE Clair Compensation provisions of the Labor Code, you most forth Power Apparatus& Large Appliances DISTRICT NO PROC SSED BV with comply with such provisions or this permit shall be deemed revoked Size Type HP, KW,KVA,or KVA L� �a Up to 1 Incl FINAL , Over 1 to 10 Incl DATE //� /1(�/�/( LICENSED CONTRACTORS DECLARATION VALIDATION Over 10 to 50 Incl Go '( `� `-'V I hereby affirm that I am licensed under provutons of Chapter _ Over 50 to 100 Inc FINAL 9 (commencing with Section 7000) of Division 3 of the Bust Over 100 BY nese and Professions Code, and my license it in full force and - effect Services - - , License Number Lic Class 0-200 Amp,Under 600 V , 201-1000 Amp Under 600 V Contractor Date Over 1000 Amp or Over 600 V i 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 S Buai Additional Sign Branch Circuits nese and Professions Code) - - �,-y. Min Conduits& Conductor A/I I, as owner of the property will do the work and the Other (See Complete Fee Schedule)— B 2 4 O 9 A structure is not intended or offered for sale (Section _ 7044, Business and Professions Code) • • • • • 2 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency 2I• • ) 7 00 for the performance of the work for which this permit u PERMIT,FEE (Sub Total) issued(Sec 3097 Civ C) - 0 e ) Z 0 0 Lenders Name PLAN CHECKING FEE (One-Fourth Permit Feel Lender's Address1 00 _B0 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 e0 County _ ordinances and State laws regulating Electrical wiring, and ' hereby authorize representatives of this County to enter upon i the ab me ned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE _ie i- �o Signe urs of PerrillLittrie Date ' WORKERS'COMPENSATIONDECLARATION 76ACE 86 606G (2 80) .� r APPLICATION FOR� ELECTRICAL PERMIT . IJ 1 hereby afftrrm.that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY, insure or a tsitaf¢ete of Worker'Com nsahon Insurance,or epe�nfi d cop the (Sec 3800, Pohcy o Comps FOR APPLICANT TO EACH NO FEE DD RE SS s J p' �y New Residential Bldgs &Pools Certdied copy s hereby furnished Q ��d� 1 &2 Famdy,Sq Ft $ — E LOCALITY ' ❑ Multi-family Sq Ft — R Certified copy a filed with the county budding Inspection CROSS ST a department Residential Swimming Pools OWNER OR FIRM NAME Dale Applicant Outlets Rec_Light_Sw _ MIL y First 20 CLRTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY Kjj Tel No } COMPENSATION INSURANCE PLAN CH 2F7 4IM EC IL APPLICANT 0 (This section need not be completed if the work mvolvad U by the permit n for one hundred dollars (SI00) or less) Lighting Fixtures Additional ADDRESS ir ToAddition Total No Add0 I certify that in the performance of the work for which thus Fixed Appliances Not Over 1 HP CITY Tel No OF permit s slued 1 shall not employ any person to any manner PERMIT C.1 ao as to become sublet[ to the Workers Compensation Laws Range_ Heater— W D W APPLICANT a Oven _ Dryer_W M _ - ADDRESS fZA Date Applicant Top _ FAU _W H Z— Hood _ Fen _Other_ CITUTel No NOTICE TO APPLICANT ,If, after making thin Certificate of Dsp _ Room Air Cond_ LICE EOR Exemption, you should become subject to the Workers RE NUMBER Clen Compensation provurons of the Labor Code, you must forth Power Apparatus& Large Appliances DISTRICT NO �y P ED BV with comply with such provisions or this permit shall be Size&Type HP,KW, KVA or KVA deemed revoked V Up[0 1 Incl r FINAL . Over 1 to 10 Incl DATE LICENSED CONTRACTORS DECLARATION Over 10 to'50 Incl l VALIDATION 1 hereby affirm that 1 am licensed under provisions of Chapter , Over 50 to 100 Inc FINAL -! 9 (commencing with Section Don 3 the Bost Over 100 BY nese and Rofesvons Code, andd my my licis ense s to fullll force and effect qqq/��,,/pServices License NumberLZ ¢ Clair ` 0 200 Amp Under 600 V 201 1000 Amp Under 600 V Contractor Dete (/ Over 1000 Amp or Over 600 V s HOMEOWNER BUILDER DECLARATION Temp Power Pole&Appurtenances _ 1 hereby affirm that I am e from the Contractors License Law for the followingg reason Additional Sign Branch with One Branch Circuit n (Section 7031 5 Bush h Circuits ' ness and Professions Code) ` I. as owner of the property will do the work and the Mix Conduits& Conductor 9 2'5A 1 AOther (See Complete Fee Schedule)— , structure s not intended or offered for sale (Section # 1 1 1 e 1 2 7044, Business and Professions Code) CONSTRUCTION LENDING AGENCY - 7 I hereby affirm that there is e construction lending agency 2'1 1 94.8 0 for the performance of the work for which this permit is PERMIT FEE (Sub Total) L,e • Q 4,8 0 issued(Sec 3097 Civ C) ' Lender's Name PLAN CHECKING FEE (One Fourth Permit Fee) 1 (109-80 Lender's Address PERMIT ISSUING FEE I certify that 1 have mad thus application and state that the TOTAL FEE above information is correct I agree to comply wtth all County, ordinances and State laws regulating Electrical wiring, and hereby allthOnza representatives of thus County to enter upon - th above mentioned property for inspectio�purpoySEE REVERSE FOR EXPLANATORY LANGUAGE Signature of P mlttee VDate i