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Home My Public Portal About5561 WELLAND AVE_Electrical__ •WORKERS'COMRENSATION DECLARATION 7BA663 CE-806G (2.80) APPLICATION FOR ELECTRICAL ' PERMIT I t eAby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY. Insurd,or a certificate of Workers'Compensation Insurance,0 a certified copy thereof(Sec.3800,Lab,C.) FOR APPLICANT TO FILL IN JOB5�111 UJ` 1 ,Policy No. Company New Residential Bldgs. EACH NO. FEE ADDRESS 'u�J Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. &Pool $ — $ LOCALITY 3 Certified co u filed with the cou t building Multi-family Sq. Ft.°e' — NEARESTate; copy' h y g inspection CROSS ST L•;J/G wk' ,&6t-_' i4 department. Residential Swimming Pools —;OWNER OR FIRM NAME " a0# 1 W Date Applicant Outlets: Rec._Light SwMAIL First ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS' Total'No. Additio al CITY Tel No. COMPENSATION INSURANCE , '• PLAN CHECK 2 (This section need not be completed if the work involved 'r APPLICANT Lighting Fixtures First 20 U by the permit is for one hundred dollars ($100) or .less.) ADDRESS N Total No. Additional O I certify that in the performance of the work.for which this CITY Tel No. permit is issued, I shall not employ any person in any manner Fixed Appliances Not Over 1 HP13 PERMITr p LJJ so as to become subject to the Workers'Compensation Laws. Range_Heater D.W._ APPLICANTPew Cf Clec ei4 1 a Oven _ Dryer_W.M._ ADDRESS , 2 / Z Dete� Applicant oZ Top _ FAU _W.H.._ �� ef a Uy Hood _ Fan _Other= . CITY AZU–M Tel No. NOTICE TO APPLICANT: If, alter making this Certiate of Disp. _Room Air Cond.— LICENSE OR q Exemption,• you should become subject to the orkers' REG.NUMBER 2a9L� Class C Compensation provisions of the Labor Code,you must forth- Power Apparatus& Large Appliances DISTRICT NO, a� PROCESED BY with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR (/!) deemed revoked. Up to 1 Incl. FINAL �� % Over 1 to 10 Incl. DATE, 146 VALI ATION LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FIN n 9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 B ness and Professions.Code, and my license is in full force and effect. Services License Numbeo Jr Z Lic.Class ef�0 0-200 Amp.Under 600 V .(�e � –7 Qyv �� ,z f ' 201-1000 Amp.Under 600 V ontractor— �Gl Date / + 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 El I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— structure is not intended or offered for sale (Section A 2-8(a 6 A 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY # o 0 0 0 0 2 I hereby affirm that there is a construction lending agency •I 0 1 6 9.8 9• for the performance of the work for which this permit is PERMIT FEE (Sub-Total) N ' issued(Sec.3097,Civ.C.). /Sq o o 169,896 Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) o 5,Q b--8 5 Lender's Address PERMIT ISSUING FEE 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-mention property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE ty". ..-.�. ZN-� ignature of Permittee Date a. •` ORK RS'COMRENSATIOfy DECLARATION k° CE-806 10/81 APPLOCATION FOR ELECTRICAL PERMIT �'I �I•hQjq�v.afiirrt► fat'I k�avg a certificate of consent to self' CE-8066 ' ,in 're-`tiY a certificate of Workers'Compensation Insurance; COUNTY OF LOS ANGELES BUILDING AND SAFETY or o.eertified copy thereof(Sec. 3800, Lab. C.) 1 'Policy No, Company I FOR APPLICANT TO FILL IN ❑ JOB Certified co is hereby furnished. EACH NO. FEE ADDRESS Py Y New Residential Bldgs..8 Pools r 1 &2-Family, S S — $ LOCALITY �Cerfified copy is filed with the county building inspec- q' Ft. — NEAREST tion department. Multi-family Sq. Ft. .-b Residential Swimming Pools CROSS ST. L_10kWee_ OWNEROR « O Date 1— S Applicant �V �� {{ FIRM NAME�.1, CERTIFICATE OF EXEMPTION FROM WORKERS' 4 MAIL First COMPENSATION INSURANCE Outlets: Rec Light Sw0 ADDRESS 305 (This section need not be completed If the work involved by ti the permit is for one hundred dollars($100)or less.) Total No. Additional CIT the (n .el. No. n_ I certify that in the performance of the work for which this APPLLIICANTK 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 Total No. Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT 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 with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. Hood _ Fan _Other_ CITY Tel. IVo. LICENSED CONTRACTORS DECLARATION DisRoom Air'CondClass. LICENSE OR `�S2Z`k I hereby affirm that I am licensed under provisions of Chapter 9 p. _ . REG. NUMBER (commencing with Section 7000)of Division 3 of the Business DISTRICT NO. / PROCESSE BY and Professions Code,and m license is in full force and effect. Power Apparatus&Large Appliances UUY Size 8 Type HP, KW, KVA, or KVAR A.Q License Number +-MA-3 Lic. ClassFINAL V Up to 1 Incl. rW65 Over 1 to 10 Inc[. DATE /j�j . .-Q 19 VALIDATION Contract- • Date Over 10 to 50 Incl. ! !J FINAL U ❑ I am exempt under Sec. Over 50 to 100 Inc. I BY 110 B.&P.C. for this reason Over 100IlYlAf U) Date: Services, Swbd., MCC&Panelboards 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 2 2 4 9 2 A SINGLE FAMILY Temp. Power Pole&Appurtenances # 0 o a o 0 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ( a a 2.550 I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and Professions Code): I o 0 0 2 5 5 0.c=i I, as owner of the property, will do the work and the Misc. Conduit"§&Conductors structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ 0 7,1 8-8 5 7044, Business 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 PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name !1 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 ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the ab tioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Q V ,SS ignature Permittee Date i