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Home My Public Portal About9619 WOODRUFF AVE_Electrical__ WORKERS'COMPENSATION DECLARATION I C-80B 10/81 APPLICATI®N IF1�® EL�'CTRICAL PERMIT I hereby affirm that I hale a certificate of consent to self insure, E-aoaG iq ,/ R. or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES, a BUILDING AND SAFETY copy thereof(Seo.3800,Lab.C.) ; + Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS ❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ _ $ LOCALITY 2y (/ CROSS ST. department. i Multi-family Sq.Ft. NEAREST J ,y n -•� Residential Swimming Pools ;�• � Gl� � Date Applicant OWNER OR r i r FIRM NAME �� CERTIFICATE OF EXEMPTION FROM WORKERS' IMAIL - r Outlets:Rec—Light_Sw.— COMPENSATION INSURANCE I ADDRESS ( y GJ L1I This section need not be completed if the work Involved b the I First 20 r CITY A JQTel.No. Total No. Additional 7 ` permit is for one hundred dollars($100)or less.) ' , I certifAPPLICANT y that jn the'performance of the work for which this permit PLAN CHECK is. issued, I shall not employ an person in a r p y y p 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 NOTICE,TO APPLICANT: If, after making this Certificate of PERMIT � � �� Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT, provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS �f •�� 1 ,provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. CITY Tel.No.07/_ LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class. (commencing with Section 7000)of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. DISTRICT NO. P SEED BY -Power Apparatus&Large Appliances j-,JN Size&Type HP,KW,KVA,or KVAR . ' , � O License Number Lic:Class Up to 1 Incl. FINAL V I Over 1 to 10 Incl. DATE ®r 2/�� VALIDATION 0 Contractor Date Over 10 to 50 Incl. ® T4 U FINAL ❑ IAM exempt under Sec. Over 50 to 100 Inc. BY OW. BAP.C.for this reason i Over 100 IL Services,Swbd.,MCC&Panelboards: Z Date. J{ 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 I Temp.Power Pole&Appurtenances o HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCT.Ir I hereby affirm that I'am exempt from the Contractor's License Law for the following reason(Section 7031.5 3303.5,Business and Professions Additional Sign Branch Circuits 70.10 ' ❑ 'Misc.Conduits&Conductors 1 ITEMS I,as owner of the property,will do the.work acid the structure I is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ® TOTAL and Professions Code). CONSTRUCTION LENDING AGENCY CHECK 70 01Q I hereby affirm that there is a construction lending agency for the I n CHANGE' °00 performance of the work for which this permit is issued(Sec.3097, I PERMIT FEE (Sub-Total) P Civ.C:). !PLAN CHECKING FEE ' .Lender's Name OL100-0001 7/278/R PERMIT ISSUING FEE a D 1601 1 AM 9°00 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 ' Apre vee. th' C untyto enter upon the above-mentioned� Insrposes. SEE REVERSE FOR EXP..LANATORY LANGUAGE ofArmee C , WORKERS'COMPENSATION DECLARATION CE 8oeG 1081 APPL�C(Y�ij B®N FOR f�.�E(P-TRICAL PERMIT I Hereby affirm that I have a certificate of consent to self insure, i or a certificate of Workers' Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY u copy,thereof($ec.3800,Lab.C.) t '• ! .. Policy No. Company " t FOR APPLICANT TO FILL IN J68 / /. _� ADDRESS V`� ❑ Certified copy is hereby furnished. 1 New Residential Bldgs.&Pools $EACH NO. FEE LOCALITY ❑ Certified copy is filed with the county,building inspection I 1 &2-Family,Sq.Ft. 27 16 _ NEAREST department. Multifamily Sq.Ft. CROSS ST. Date' Applicant Residential Swimming Pools OWNER OR FIRM NAME09 CERTIFICATE OF EXEMPTION FROM.WORKERS' iOutlets:Rec—Light—Sw. MAIL — -. COMPENSATION INSURANCE i ADDRESS GRs (This section need not be completed•if the work Involved by the ' First 20 CITY Tel.No. y permit Is for one hundred dollars($100)or less.) Total No. Additfonaf 2/ I certify that in the performance.of the work for which this permit PVCAD K 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 Date I d Applicant �1 Total No. CITY Tel.No. NOTICE TO APPLICANT: If, after- making this ,Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. APPLICANT /•+ ��!' ac provisions of the Labor Code,you must forthwith comply with such 'e Oven _ Dryer_ W.M._ ADDRESS• 7S provisions or this permit shall be deemed revoked. ;i Top _ FAU _ W.H. _ CITY r '7 Tel.No. 0 LICENSED,CONTRACTORS DECLARATION Hood — Fan _ Other— hereby hereby affirm that I am licensed under provisions of Chapter 9 LICENSE oR �f Disp. — Room Air Cond. REG.NUMBER Q rp�j Class. gf-J0 (commencing with Section 7000)of Division 3 of the Business and , Professions Code,and my license is in full force and effect. i Power Apparatus&Large Appliances DISTRICT NO. SED BY7 ✓ p' Q 1 p I• Size&Type HP,KW,KVA,or KVAR Q License Number W/ ,4 Lic:Class I Up to 1 Incl. FINAno L '1Over 1 to 10 Inc[. DATE ?V VALIDATION Contractor ® V �°n�x`c_�2C46ate 10 -131 — � Over 10 to 50 Incl. FINAL � ❑ 1 am exempt under Sec. Over 50 to 100 Inc. B.Y a j B.&P.C.for this reason I Over 100 N Services,Swbd.,MCC&Panelboards Dater 0-200 Amp.Under 600 V 1 Signature .I 201 - 1000 Amp.Under 600 V Over 1000 Amp,or-Over 600 V ❑ Exemption for Reg.Maint.Elect. i SINGLE FAMILY Temp.Power Pole&Appurtenances 'HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCT-4 I hereby affirm that I am exempt from the Contractor's License Lawf Additional Sign Branch Circuits for the following reason(Section 7031:5,Business and Professions, 3303 576.06 Code): Misc.Conduits&Conductors 1 ITEM ❑ I,as owner of the property,will do the work and the structure' -- is not intended or offered for sale (Section 7044, Business- Other(See Complete Fee Schedule) _ • TOTAL 326 o 06 and Professions Code). ® DECK 326.0f►' CONSTRUCTION LENDING AGENCY CWGE - ' 000 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 -0001 11/-7/95 Lender's Name I h PERMIT ISSUING FEE d Q Lender's Andress I �r B6 3184 1 AC910-036 I certify that I have read this application and state that the above TOTAL FEE cJ��• 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 EppAKty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE a of Permittee Date i •