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Home My Public Portal About6242 SULTANA AVE_Electrical__ yVORKERs'COMPENSATION DECLARATION -8 10,81 CE-806G APPLICATION FOR ELECTRICAL PERMIT 0t3 �ereby affiM that I have a certificate of consent to self insure, • &_r.dartificate of Workers' Compensation Insurance;or a certified .COUNTY OF LOS ANGELES BUILDING AND SAFETY capy thereof(Sec.3800,Lab.C.) Policy No. Company FOR APPLICANT TO FILL IN JOB /t/M1 7- AD4RE3§ /✓ ❑ Certified copy is hereby furnished. • New Residential Bldgs.&PoolEACH NO. FEEs $ _ $ LOCALITY ❑ Certified copy is'filed with the county building inspection 1 &2-Family,Sq.Ft. department, Multi-family Sq.Ft. NEAREST ZI IF CROSS � Sl Ga' Date Applicant Residentiai.Swimming Pools OWNER OR FIRM„NAME ' CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec2l Light ZZ sI'.',.J-t::J' 4AMAIL. COMPENSATION INSURANCE f 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 �j, CITY—/-f Tel,No. S` 1 1 certify that in the'performance of the work for which this permit PPLANCCHECK . is 'issued,.1•shall not employ any person in any manner so as to become subject to the Workers'Compensation s.. Lighting Fixtures First 20, •ADDRESS 1 Additional Total No. CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE. TO APPLICA T. If, of making this ertifi of Exemption,you should become subject to the Worke Compe ation Range Heater D.W. APPLICANT Provisions of the Labor Code,you must forthwith comply with such Oven Dryer.— W.M.— ADDRESS provisions or this permit shalt be deemed revoked. Top FAU_ W.H. —' CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood _ Fan Other_ I hereby affirm that 1 am licensed under provisions of Chapter 9 �Z LICENSE OR (commencing with Section 7000')of Division 3 of the.Business and Disp. Room Air'Cond.. RE.G..NUMBER' Class. Professions Code,and my license is in full force and effect. Power-Apparatus:&Large Appliances , DISTRICT No. /) PROCESSED Y Size&Type.HP,KW,KVA,,or KVAR v fO License Number Lic,Class Up to 1 Incl. FINAL Q Over 1 to 10 Incl. DAT.. O Contractor Date ' F' VAL- ON . Over 10 to 50 Incl. ❑ I am.exempt under Sec. 15 Over 50 to 100 I.nc. W Over 100' 1% ' BAP.C.:for this reason N Services;Swbd.,MCC&Panelboards /�1, Z Dater - .. 0-200 Amp.Under'600 V 4fy/�y� 'L v Signature 201 - 1000 Amp.Under 600 V V ❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V SINGLE FAMILY Temp.Power Pole&.Appurtenances HOMEOWNER-BUILDER DECLARATION -' Sign with One Branch Circuit I hereby affirm that I am exempt from tAe Contractor's License Law r for the following reason(Se !on 7031.5,Business and Professions• Additional Sign Branch CiPcuits Code): Ih Mist.Conduits&Conductors J!� I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) is riot Intended or offered for sale (Segtion 7044, Business and,Professions Code). CONSTRUCTION'LENDING AGENCY I hereby affirm that there is a construction lending agency for the 3307t''z( Performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) r Civ.C.). ,• ' � rb PLAN CHECKING.FEE TOTAL 64 _50 Lender's Name PERMIT ISSUING-FEE 5.� CHECK 64.50 Lenders Address a4 I I certify that I have read this application and state that the above TOTAL FEE �� CHANCE. , 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 ;, 1/1t property for in action purposes, SEE REVERSE FOR EXPLANATORY LANGUAGE e+"II AN 9 0131 Sigftrurt.o rmi a Date 7 i WORKERS'COMPENSATIONDEC:LARATION76A663 CE$OBG (2-8O) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES C BUILDING AND SAFETY insure,or a certificate of Workers'Compensation Insurance,or ! s a certified copy thereof.(Sec.3800,Lab.C:) i FOR APPLICANT TO FILL IN j08 Policy No. Company EACH NO. FEE ADDRESS L � NOW.Residential Bldgs.&Pools i ❑ Certified copy is hereby furnished. 1 &2-Family,Sq.Ft. $ — $ LOCALITY Multi-family❑ Sq..Ft. NEAREST Certified copy is filed with the county building inspection CROSS ST department. Residential Swimming Pools OWNER OR �f LA �� Date Applicant .FIRM NAME (�s� L..�1 �YQ, A Outlets:Rec. Light First z .2 ADDRESS SA rYl CERTIFICATE OF EXEMPTION FRbM WORKERS' Total-No. a-01— Additional CITYT o. CQMPENSATION.INSURANCE PLAN CHEC d APPLICANT O (Thi-s suction-.need.not be completed if the work involvedLighting Fixtures First 20 t V by the permit is for one hundred dollars ($100) or less.) - - ADDRESS' , Total No. Additional =I certify that in the performance of the work for which this CITY Tel No. 0 Fixed Appliances Not.Over 1 HP permit is issued, I shall not employ any person in any manner 'PERMIT so as to become subject to the Workers'ComD tion Laws. Range_Heater D.W._ APPLICANT +..1 l� '/Z/� C�.e��s�• `d• a Oven — Dryer_W.M._ ADDRESS d �� j/Nl/ad.S Z'Date Applicant Top _ FAU _W.H. ,r, Hood _ Fan _Other_ CITY Tel No. NOTICE Tb APPLICANT: If, ter making this Certificate ofDisp. _Room Air CondLICENSE OR Exemption, .you should become subject to the Workers' om REG.NUMBER lass Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances DISTRICT NO.. PROC .SEDwBY with comply with such provisions or this permit shall be deemed.revoked. Size&Type HP,KW,KVA,or KVAR Up to 1 Incl. � Over 1 to 10 Incl. FINAL , LICENSED CONTRACTORS DECLARATION DATE �! �,j VALIDATION Over 10 to 50.Incl. F 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 BY I ness and Professions;Code, and my license is in full force and effect. Services 7' �� 0-200 Amp.Under 600 V- License Number_.� Lic.Class =� l 201-1000 Amp.Under 600 V Contract ate l '�'��'� Over 1000 Amp.or Over 600 V 100, ME 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.7033.5, Busi- 'Additional Sign Branch Circuits ness and Professions Code): i r Misc.Conduits&Conductors 2 5 7.3 A, Ell, as owner of the properly,will do the work and the Other(See Complete Fee Schedule)— structure. is not intended -or offered, for sale (Section I tL 0 0 0 0 0 2 7044,1 Business and Professions Code). r CONSTRUCTION LENDING AGENCY r I hereby affirm' that there is a construction lending agency i ' � ° o 2 u'7 0 for the performance of the work for which this permit is issued(Sec:3097,Civ.C.). i PERMIT FEE – (Sub-Total) = c ° o. 2 4 7(1 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee). 01.08' L Lender's+Address PERMIT ISSUING FEE i I certify that I have read-this application and' state that the II TOTAL FEE �I above information is correct:I agree to comply with all County ordinances and State laws r. ulating Electrical wiring, and I hereby authorizer se s of this County to enter upon , rr the ab enti ed y Yor inspection purposes. ' SEE'REVERSE FOR E14PLANATORY LANGUAGE I i u f er it fie e_ Date