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Home My Public Portal About6361 SULTANA AVE_Electrical__ • WORKERS'COMPENSATION DECLARATION 78-883 10/e1 APPLICATION FOR ELECTRICAL PERMIT I Hereby affirm that•I have a ivrliflcrtf&' of consent t self insure, CE-808G or ..rtificate pf workers' Compensation Insura ora certified COUNTY OF LOS ANGELES BUILDING AND SAFETY y°op, of(Sec.3800,Lab.C.) Policy N Compan 1A Q FOR APPLICANT TO FILL IN JOB i ❑ EACH NO. FEE ADDRESS •/ Certified c is he Wished. New Residential Bldgs.&Pools FL-&- _ ❑ 1 &2-Family,Sq.Ft. $ _ $ LOCALITY Certified copy filed with the county building inspection depart an Multi-family Sq.Ft. NEAREST CROSS ST Date Applicant Residential Swimming Pools OWNER OR FIRM NAME RTIF ATE OF EXEMPTION FROM ERS' Outlets:Rec_Light—Sw.— MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed If the work Involved by the First 20 CITYTel. permit Is for one hundred dollars($100)or less.) Total No. Additional S �e PLAN CHECK I certify that in the performance of thework f which this permit APPLICANT is issued, I shall not employ any perso in manner so as to become subject to the Workers'C$mp at s ' n Lighting Fixtures First 20 ADDRESS � �0 _� Total No. Additional CITY Tel.No. Date Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, making is Certificate" of APPLICANT Gr� Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS Q = d provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ CITY Tel.No. -LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ h� �� I hereby affirm that I am licensed under provisions of Chapter 9LICENSE OR Disp. — Room Air Cond. REG.NUMBER.L U Class. (commencing with Section 7000) of Division 3 of the Business and Professions Code,and my license is in full force and effect. DISTRICT NO. PROC S BY Power Apparatus&Large Appliances �/ License Number � C.- Size&Type HP,KW,KVA,or KVAR t - 1w4f—�, U Lic.Class Up to 1 Incl. FINAL / Over 1 to 10 Incl. DATE Contractor, sa Date VALIDATION 0 � Over 10 to 50 Incl. FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY 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 ❑ 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 for the following reason(Section 7031.5,Business and Professions Code): 3307 3 1=L r, El 1, Conduits&Conductors I,as owner of the property,will do the work and the structure HE ` is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) and Professions Code). i 07AL 33 o 0113 CONSTRUCTION LENDING AGENCY �-I'HE CK :;_U,- 1 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) db CHANGE .01-1 Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE d Lender's Address 3555 1 Aid 1 Z o 134 I certify that I have read this application and state that the above TOTAL FEE 3 information is correct.I agree to comply with all County ordinances and State la reg mg Electrical wiring, and hereby authorize representati of i to enter upon the above-mentioned pro y p15pe i purp es. SEE REVERSE FOR EXPLANATORY LANGUAGE �v G atu of Permitte • WORKERS'COMPENSATION DECLARATION 40.0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O P hereby affirm that I have a certificate of consent to self cpeeoeG ,insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS -or a certifie copy I ereof Sec. 3800, Lab. C.) Policy IVo. "Company FOR APPLICANT TO FILL IN JOB ❑Certified co is hereby furnished. ! EACH NO. FEE ADDRESS 0.11G1 V , PY Y a�/�/ New Residential Bidgs. &Pools ®Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. /17 $ �� — $ LOCALITY �� tion department. NEAREST �1� Multi-family Sq. Ft. CROSS ST. Date I A Applicant+' Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_.)_0Light. Sw.1. MAIL COMPENSATION INSURANCE ADDRESS t.c I ta11Q. Ave. (This section need not be completed if the work involved by First tCIN /� Tel, No. the permlt is for one hundred dollars($100)or less.) Total No. Additional C7 PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Additional A Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION -QY Q. Exemption, you should become subject to the Workers' Range Heater—D.W. J Compensation provisions of the Labor Code, you must forth- Oven Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be Top FAU ---W.H. — &�& deemed revoked. CITY Tel, No Hood Fan -'—Other_ 0ln LICENSED CONTRACTORS DECLARATION LICENSE OR Class. I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER - (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. P O ESSED BY a and Professions Code,and my license is in full force and effect. p /� Size&Type HP, KW, KVA, or KVAR co O License Number bo 1 qq S Lic. Class- C Up to 1 Incl. FINAL ' �>J p[. Over 1 to 10 Incl. DATE 2 VALIDATION W Contractor 4� LSC Date - v 0 ❑ _ Over 10 to 50 Incl, U FINAL I am exempt under Sec. Over�O to 100 Inc. BY �J-,�.� LU B.&P.C. for this reason Over 16-0--l. IJ%' -� 0- Services, Swbd., MCC&Ponelboards Z Date: 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V 4 ❑ Exemption for Reg. Maint. Elect. 1 SINGLE FAMILY Tem<'P wer Pole&A� HOME OWNER-BUILDER DECLARATION P• -Q.,_ ppur antes I hereby affirm that I am exempt from the Contractor's License Sign with One Branch rrcLTt Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Ell, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ ` o � Business and Professions Code). :` -j i CONSTRUCTION LENDING AGENCY 4 l I hereby affirm that there is a construction lending agency for 10H the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 441- "-1= (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE - t Lender's Address Z.-.1= 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 ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date ®s