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Home My Public Portal About9536 WEDGEWOOD ST_Electrical__ ►iy• I WORKERS'COMPENSATION DECLARATION j,f CE BOBG CE-806APPLICATION FOR ELECTRICAL PERMIT I hereby•affirm that I have a certificate of content to self insure, •I or a certificate of Workers' Compensai&VIrisurance, 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 y�r ti ❑ Certified copy is hereby furnished. I' New Residential Bldgs.&Pools EACH NO. FEE ADDRESS (, (j(y ❑ 1 &2-Family,Sq.Ft. $ _ $ LOCALITY Certified copy is filed with the county building inspection; department. ,f Multi-family Sq.Ft. NEARESTCROSS ST. Date Applicant ', Residential Swimming Pools OWNER ORf g�� ( r ;FIRM NAME ( � •� r CERTIFICATE OF EXEMPTION FROM WORKERS' ' Outlets:Rec—Light—Sw.— MAIL ► COMPENSATION INSURANCE ADDRESS This section need not be completed if the work Involved First 20 ( P b Y the CITY Tel. permit is for one hundred dollars($100)or less.) Total No. Additional PLAN CHECK 1 certify that in the performance of the work for which this permit APPLICANT is issued, I shall not employ any person in any manner so a t become s bject to the.Workers'Compensate Law Lighting Fixtures First 20 I ADDRESS p Total No. Additional. CITY T Date `f Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after ma an this Car ifi to of APPLICANT 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 provisions or this permit shall be deemed revoked. Top — FAU W.H. _ d ':' CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ 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 '� ' Professions Code,and my license is in full force and effect. % Power Apparatus&Large.Appliances j DISTRICT No:S_ PROLE SED BY Size&Type'HP,KW,KVA,or KVAR 0 License Number Lic.Class " , Up to 1 Incl. i FINAL V Over 1 to 10 Incl. ' DAT __Z Z _lev LIDATION n= Contractor Date0 Over 10 fo 50 Incl. FINAC ❑ I am.exempt under Sec. ' Over 50 to 100 Inc: gY B.&P.C.for this reason {` Over 100 + + I '` d Services,Swbd.,MCC&Panelboards Date.— 0-200 Amp.Under 600 V 1 a Signature 201 - 1000 Amp.Under 600 V 8 3 2 3 A Over 1000 Amp.or Over 600 V 22 ❑ Exemption for Reg.Maint.Elect. �`o 0•0 0 0 2 SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION i Sign with One Branch Circuit Io' -,2S 5 0 1 hereby affirm that I am exempt from the Contractor's License Lawj Additional Sign Branch Circuits for the following reason(Section 7031.5,Business and Professions- 0 0 0 2 O,5 0 6 Code): 1,as owner of the property,will do the work and the structurei Misc.Conduits&Conductors t �, o9-87 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.)., j PLAN CHECKING FEE Lender's Name ; PERMIT ISSUING FEE Lender's Address /r 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 11 spection SEE REVERSE FOR EXPLANATORY LANGUAGE IL I Si a of Permittee Dae WORKERS'COMPENSATION DECLARATION 76;883 10/81 APPLICATION FOR ELECTRICAL PER i7IT I hereby affirm that I have a certificate of content to self insure, CE;soeG � If� AA�r �lPERMIT or a certificate of-Workers' Compensation`insuranLm, or a cdrtified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab.C.) s fl Policy No.AM-OOP7 Company STIP A"to FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS 534 Yvis lFruvold S7—. Certified copy is filed with the county building Inspection 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY u' G 06, department. Multi-family Sq.Ft. NEAREST CROSS ST.p Residential Swimming Pools OWNER OR �G4OwA Date Applicant FIRM NAME /htQ. tE CERTIFICATE OF EXEMPTION FRO WORKERS' � MAIL Outlets:Rec Light t 2 S�� COMPENSATION INSURANCE � j® 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.J-1— Additional CITY Tel. 1 certify that in the performance of the work for which this permit APPLICANT CHECK 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 Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater,- D.W. _ APPLICANT Rfil"310ELeRJ It a 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 _. W.H. CITY JV�T Col//IIIA C Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ 1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. L in no LICENSE OR o (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER !&578q sass v`'� Professions Code,.and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT N P ED Size&Type HP,KW,KVA,or KVARfly8 License Number Lic.Class Up to 1 Incl. pATEL v: Over 1 to 10 Incl. VALIDATION Contractor Date Over 10 to 50 Incl. FINAL ❑ I am exempt der Sec. Over 50 to 100 Inc. BY W BAP.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 nr 'a I hereby affirm that I am exempt from the Contractor's License Law '+��( �z for the following reason(Section 7031.5,Business and Professions Addit!one]Sign Branch Circuits Code): =-C. ElMisc!Conduits&Conductors I,as owner of the property,will do the work and the structure MS is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ T TAL 44 o 60 and Professions Code). CONSTRUCTION LENDING AGENCY �4ECK 44.6- I hereby affirm that there is a construction lending agency for the CHANGE %IIS performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total) Civ.C.). PLAN CHECKING FEE Lender's Name 11300-000 7/ 2/ -i PERMIT ISSUING FEE =59 y 1 AMI] 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 i epecti urpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE e � D r S' atw of Permittee JF Crate