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HomeMy Public PortalAbout6027 SULTANA AVE_Electrical__ WORKER S'COMPENSATION DECLARATION :CE-SQ36G (2.80) APPLICATION FOR ELECTRICAL PERMIT CE-80 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES (2 BUILDING AND SAFETY insure, or a certificate of Workers'Compensation Insurance,or ! 11 a certified copy thereof(Sec.3800,Lab.C.) FOR APPLICANT TO FILL IN JOB &,,eL=K41 Policy No. Company EACH NO. FEE ADDRESS !d New Residential Bldgs.&Pools ❑ Certified copy is hereby furnished. 1 &2-Family.Sq. Ft. $ — Is LOCALITY ElCertifiedSq. Ft. NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAME Date Applicant Outlets: ReCA Light Sw. MAIL First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY p Tel No. } COMPENSATION INSURANCE PLAN HECK tl APPLICANT (This section need not be completed if the work involved U by the permit is for one hundred dollars ($100) or less.) Lighting ixtures First 20 ADDRESS / Additional I certify that in the Tgtal No._ O performance of the work for which this CITY Tel No. Fixed Appliances Not Over 1 HP permit is issued, I shall not employ any person in any manner PERMIT W so as to become subject to the Workers Compensation Laws. Range Heater D.W._ APPLICANT a �(// Oven — Dryer_W.M._ ADDRESS N j(Date "-f f -Applicant Top _FAU _W.H.._ Z dr Hood _ Fan _Other— CITY Tel Na. NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond.— ILICENSE OR ey Exemption, you should become subject to the Workers' REG.NUMBER S Class �V 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 Size&Type HP,KW,KVA,or KVAR �iQ deemed revoked. Up to 1 Incl. J / Over 1 to 10 Incl. FINALDATE VALIDATION LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. r 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 ness and Professions Code, and my license is in full force and C effect. Services lX� ell�T -'/O 0-200 Amp.Under 600 V License Number D Lic � 1 .classls' •201-1000 Amp.Under 600 V y/L Contractor ate /� Over 1000 Amp.or Over 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&Conductors I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— l ti 1, 1 A structure is not intended or offered for sale (Section 7044,Business and Professions Code). 3: o u u o o r CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency , o o 26 C (� for the performance of the work for which this permit is issued(Sec.3097,Civ.C.). PERMIT FEE (Sub-Total) u :1 o ;: L Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) �, % Lender's Address PERMIT ISSUING FEE ,> C01 —r I certify that I have read this'application and state that the r TOTAL FEE / above 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 inspection purposes. I SEE'REVERSE FOR EXPLANATORY LANGUAGE i Signature of er Date i �i'WCfiKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT a V:he4b;-ail ir4that I have a certificate of consent to self insure. CE-806G or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec. 3800.Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS i New Residential Bldgs.& Pools ❑ 1 & 2-Family, Sq.Ft. $ _ $ LOCALITY Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. NEAREST CROSS ST, Date Applicant Residential Swimming Pools OWNER OR _. FIRM NAME 1 �..• CERTIFICATE OF EXEMPTION FROM WORKERSOutlets:Rec— Light Sw. — MAIL COMPENSATION INSURANCE ADDRESS This section need not be completed if the work involved b the First 20 ( y Total No. Additional CITY -� Tel.No. permit is for one hundred dollars ($100)or less.) that in the performance of the work for which this permit PLAN CHECK I certify P APPLICANT 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 Additional � Total No. CITY Tel.No. Date Applicant I Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APP ICA T: If, after makin this Certi Icate of q ,. S /` Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT P_f provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer W.M. _ ADDRESS .2Z provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _ LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY z�jfa s I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR Disp. Room Air Cond. REG.NUMBER Class.' (commencing with Section 7000) of Division 3 of the Business and 3 C f�- . Professions Code,and my license is in full force and effect. DISTRICT NO. P C SED BY Power Apparatus& Large Appliances / Size& Type HP,KW,KVA,or KVAR ( (_ ; t a License Number 61�I�� Lic.Class Up to 1 Incl. FINAL O SL 114 O QI— Over 1 to 10 Incl. DATE N 0 Contractor J VALIDATION Over 10 to 50 Incl. FINAL ~ I am exempt under Sec. Over 50 to 100 Inc. BY W BAP.C. for this reason Over 100 CL Se ry es, Swbd.,MCC& Panelboards Z Date: ' 0- 200 Amp.Under 600 V x Signature / 201 - 1000 Amp.Under 600 V F] Exemption 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole& Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ► 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) Civ.C.). PLAN CHECKING FEE Lender's Name _ PERMIT ISSUING FEE t Lender's Address I certify that I have read this application and state that the above TOTAL FEE 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 inspection purposes. W44n SEE REVERSE FOR EXPLANATORY LANGUAGE l ✓ t2 L Signature of mitt a e , f p� p /� ww�'1 ' ' 1�IORKF�RS COMPENSATION DECLARATION CE 808G 10�Bi ARPLICATI®9�i.1• R ELECTRICAL PERMIT 4� .reby,i ff.'hR that I have a certificate of consent to self insure, or a certificate of Workers' Compensation Insurance, or a certified copy thereof(Seo.3800,.Lab.C:) COUNTY OF LOS ANGELE BUILDING AND SAFETY Policy NO. Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. EACH NCS. FEE ADDREs3 New Residential Bldgs.&Pools ❑ 1 &2-Family,Sq:Ft. $ --i $ LOCALITY Certified copy is filed with-the county building inspection department. Multi-family Sq.Ft. — NEAREST CROSS ST Date Applicant Residential Swimming Pools OWNER OR 5,FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' -COMPENSATION INSURANCE Outlets:RecLight - Sw. 7n ADDRESS Ayf (This section need not be completed if the work involved by the First 20 l EJ permit is for one hundred dollars.($100)or less.) ,Total No. Additional. CITY T.I.No. (Q,.�( P I certify that in the performance of the work for which this permit PLICANT is issued, I shall not employ any person in any manner so as to become sub'ect to the Workers'Comp nation Laws Lighting Fixtures First 20. ADDRESS Additional Total No.. CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP NOTICE APPL CANT: if, after aking this Certificate.' of, (PERMIT Exemption,.you should,become-subject. the Workers'Compensation Range_ Heater D.W. APPLICANT 1/�/ 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 _ WH, f CITY Tel.No.. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE.OR (commencing with Section•7000)of Division 3 of the Business and Disp. - Room Air Cond, REG.NUMBER Class. ' Professions Code,and my license is in full forceand effect. Power Apparatus&Large Appliances DISTRICT NO. PROCE D BY Size&Type HP,KW,KVA,or KVAR © Al 'License Number Lia Glass Up to 1 Incl. FINAL Over 1 to 10 Incl, DATE k—//r O Contractor Date , VALIDATION . Over 10 to 50 incl. FI ❑ 1 am exempt under,Sec:. Over 60 to 100 Inc. g 5 LLI BSP.C.for this reason Over 100 Services,Swbd.,MCC&Panelboards Z 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 FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ` I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits i t;'I�• for the.following reason(Section 7031.5,Business and Professions Code): 4-7 o -- Misc. r I,as owner of the property,will do the work and the structure Conduits&Conductors '7 ^.cZ is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ and Professions Code). ® CHANGE 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.) I l,j"l,—j tf_i.� 2i 6-139 Civ,.C:). PLAN CHECKING FEE `( Ar.. 9 Lender's Name' PERMIT ISSUING FEE Lender's Address. - ` I certify that I have read this application and state that the above. TOTAL FEE information is correct.-1 agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize , rep sen tatives of this County to enter'upon the above-mentioned pro rty for inspection purposes.. SEE REVERSE,.FOR EXPLANATORY LANGUAGE n ure.of Permittee aa- 9e 1. f ` OFjKERS'COMPENSATION DECLARATION CE-806G '0'81 APPLICATION FOR ELECTRICAL PERMIT I,hery a firm that I have a certificate of consent to self insure, .Ua•a Nrtlflt:ate of Workers'Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800.Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS 90 a �io 0'I�i /•c - New Residential Bldgs.&Pools ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ _ $ LOCALITY department. Multi-family Sq.Ft. NEAREST Residential Swimming Pools CROSS ST. 6- Date Applicant OWNER OR ..— FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' � MAIL Outlets:Rec Light Sw. COMPENSATION INSURANCE fZ7 74 � O ADDRESS (This section need not be completed if the work Involved by the First 20 permit Is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.No. I certify that in the performance of the work for which this permit PLAN CHECKAPPLICANT is issued, I shall•not employ any person in any manner as to become subject to the Workers'Compen ation Laws. Lighting Fixtures First 20 ADDRESS p Additional Date 5 v Applicant �wL � J- Total No. CITY Tel.No. NOTIC TO APPLICANT: If, after king this Certificate _r— Fixed Appliances Not Over 1 HP PERMIT Exemption,you should become subject o he Workers'Compensation Range_ Heater D.W. _ APPLICANT provisions of the Labor Code,.you mus forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top _ FAU _ W.H.._ CITYTel.No. LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_ I 1 hereby, affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. LICENSE OR Class. (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER ' Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRI P E Up to 1 Incl. FINAL ED BY >0 Size&Type HP,KW,KVA,or KVAR v 0 License Number Lic.Class COQ 10 Over 1 to 10 Incl. DATE Contractor Date VALIDATION C Over 10 to 50 Incl. WB Elam exempt under Sec. Over 50 to 100 Inc. W B.&P.C.for this reason Over 100 , N' Services,Swbd.,MCC&Panelboards Z Date: 0-200 Amp.Under 600 V Signature 201 - 1000 Amp.Under 600 V ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V i h SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit y I hereby affirm that I am exempt from the Contractor's License Law additional Sign Branch Circuits Av'` "4 for the following reason(Section 7031.5,Business and Professions Code: 1 4?)l7 29.01C Misc.Conduits&Conductors t I,as owner of the property,will do the work and the structure i 1a is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ and Professions Code). ® TOTAL 29 o 00 1 CONSTRUCTION LENDING AGENCY 4S HEY 19.CIC 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) �� Civ.C.). PLAN CHECKING FEE 1 Lender's Name tl,i(Y -O to l 3/16/3;' '^ PERMIT ISSUING FEE 0 Lender's Address Cz 1 AN V a35 s 1t I certify that I have read this application and state that the above TOTAL FEE. information is correct.I agree to comply with all County ordinances and.State laws regulating Electrical wiring; and hereby authorize re resentatives of the- � nter upon the above-mentioned P perty for inspecti SEE REVERSE FOR EXPLANATORY LANGUAGE Armv_ 6r U i ature of Permittee Date