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HomeMy Public PortalAbout6121 SULTANA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION76-806 iD,B, APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self E-806 i 6 insure, or a certificate of Workers'Compensation Insurance, ( COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof(Sec. 3800, Lab. C.) Policy No, Company FOR APPLICANT TO FILL IN JOB EACH NO. FEE ADDRESS 2i Certified copy is hereby furnished. New Residential Bldgs. 8 Pools 1�3/11certlfieccopy is filed with the county building inspec- 1 8 2-Family, Sq. Ft. $ $ LOCALITY — ell tion department. Multi-family Sq. Ft. — NEAREST Date -7 ^� �/ Residential Swimming Pools CROSS 5T. PPlicanT�Y�EF /G FlRM NAME f•JC.�c -iV CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec MAIL COMPENSATION INSURANCE . Light First 20 ADDRESS�✓Y c��-I/T���T (This section need not be completed if the work involved by Total No. Additional CITY � 1P[«/ Tel. No.2,966` 9 the permit is for one hundred dollars($100)or less.) I certifythat in the performance of the work for which this PLAN CHECK e p APPLICANT permit is issued,I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS it Total No. Additional CITY Tel.'No. Date Applicant I Fixed Appliances Not Over 1 HP PERMIT �+ � NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT O'14;FF CC.^ C MIeC Exemption, you should become subject to the Workers' Range_ Heater_D.W. — Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M.— ADDRESS �� l$ with comply with such provisions or ,this permit shall be Top — FAU Hood Fan _Other_—W.H. — - . deemed revoked. CITY Aei7L Tel. No.72,J,�2'_LICENSED CONTRACTORS DECLARATION LICENSE ORI hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER 3 '�S2 7 Class. (commencing with Section 7000)of Division.3 of the Business I Power Apparatus 8 Large Appliances DISTRICT NO. PRO ED BY and Professions Code,and my license is in full force and effect. +. d ? 27 Size 8 Type HP, KW, KVA, or KVAR• d 0 License Number r7 Lic. Class el© V 'i Up to 1 Incl. FINAL._ O T .' Over 1 to 10 Incl. DATE �" VALIDATION 090 Contractor G ate Over 10 to 50 Incl. V ❑ FINAL. / I am exempt under Sec. I Over 50 to 100 Inc. BY2� M Over 100 y B.BP.C. for this reason Z Date: Services, Swbd., MCC 8 Panelboards / ► 0 -200 Amp. Under 600 V J. Signature 201 -1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY Temp. Power Pole 8 Appurtenances HOME OWNER-BUILDER DECLARATION J 7,6 Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License i Additional Sign Branch Circuits a o 0 0 o i J' Law for The following reason (Section 7031.5, Business and .. _ Professions Code): ❑ I, as owner of the property, will do the work and the I Misc. Conduits 8 Conductors ° o r-- structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ► 'o rr 7044, Business and Professions Code). I 2 )c CONSTRUCTION-LENDING AGENCY i 07 1 2-8'31 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued i 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 TOTAL FEE ' above information is correct. I agree to comply with all County rdinances and State laws regulating Electrical wiring, and her uthor' e r tives of this County to enter upon the.abov men io d pr ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Pe ittee Date 4 WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT hereby affirm that I have a certificate of consent to self insure, 76A663 dr a certifiaete of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY a — Certified copy is filed with the county bulkligg i1 &2-Family,Sq.Ft. $ $nspectio — NEAREST depadjnent. Multi-family Sq.Ft. CROSS ST. Date Applicant 7 Residential Swimming Pools ASSESSOR MAP BOOK PAGE PARCEL CERTIFICATE OF EXEM 10 FROM WORKERS' OWNER OR COMPENSAT N SURANCE Outlet�s:/,R�ec. Light-/Fir— 20IRM NAME ��Jj�j/ S�,X,) (This section need not be co pi ed If the work Involved by the ` ADD ADDRESS permit is for one hundred do ($100)or less.) (!!%%% al No. Additional I certify that in the performance of the work for which this permit CITY Tel.No�� is issued, I shall not employ any person in any manner so as to PLAN CHECK LY become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 -APPLICANT p Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code,you must forthwith comply with such APPLICANT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances / LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS JAI �.� I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000) of Division 3 of the Business and CITY pL Tel.No. Professions Code,and my license Is in full force and effect. Over 106 to 50 Incl. }. LICEAE OR � Over 100 DISTRICT NO. P 7 SSED BY Class. j Over 50 to 100 Incl. REG.NUMBER O/ / O License Number L`1 907 Lic.Class 1U Services,Swbd.,MCC&Panelboards Contractord/fAI&f LAC—Data Z !l_ 0-399 Amp.Under 600 V DATE I- ❑ 400-1000 Amp.Under 600 V g S�� VALIDATION V lam exempt under Sec. Over 1000 Amp.or Over 600 V FINAL d B.&P.C.for this reason BRANCH CIRCUIT FEES BY co Date: 15A,or 20A,120V,Lighting or Recept. 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits JL SINGLE FAMILY Temp.Power Pole&Appurtenances ACCToa HOME OWNER-BUILDER DECLARATION n with One Branch Circuit 2 �1 4� I hereby affirm that I am exempt from the Contractor's License Law Sig330,E for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 1 ITEMS Code): �1 ,e-1, ❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 41 o 40 is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) CHECK 41.40 and Professions Code). CONSTRUCTION LENDING AGENCY K�nl�L� CHANGE o00 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) � 0000-0001 7/18/96 �- PLAN CHECKING FEE Lender's Name��'� n�� ` � 7529 1 AM Qe05 PERMIT ISSUING FEE =;2 Z, Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE A110 that the 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 insSEE REVERSE FOR EXPLANATORY LANGUAGE SIGNAT}J E OP PERI II DA