HomeMy WebLinkAbout9456AWORKER S'COMPENSATION DECLARATION
CE-806G 12-80) APPLICATION
CEEOo
FOR ELECTRICAL PERMIT
I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES
BUILDING AND SAFETY
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3900, Lab. C.)
FILL IN
JOB
ADDRESS Lot #70-1330 S. Red Bluff
o-A9h0/r lir,,,,, ,,„r T„Ae,„„�� FOR APPLICANT TO
Poli ompany
ew Residential 61dgs. &Pools
Certified copy is hereby furnished. 1 & 2-Family,Sv. Ft._2929
EACH
NO.
FEE
$
—
$
LOCALITY TR - Rowland
—
ARE T
CROSS ST
Multi -family Sq. Ft.
Certified copy is filed with the county building inspection
department. Residential Swimming Pools
Date 3-3-81 Applicant "C" ZV r a-e F.1 2 C t" ' t tlets: Rec.3Light1_ Sw.
First 20
OWNER OR
FIRM NAME The PresleyCompany
MAIL
ADDRESS 4600 ampus Drive
CITY Tel No. _0-50
Reach
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional
COMPENSATION INSURANCE
part
PLAN CHECK
(This section need not be completed if the work involved
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20
Additional
Total Na.1_
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. —
60
APPLICANT
ADDRESS
CITY Tel No.
PERMIT "C"
APPLICANT C McGee Electric,
ADDRESS P.O. BOX 2886
e Oven _ Dryer _ W.M. _
Date Applicant Top _ FAU- _ W.H.—
Hood _ Fan —Other —
CITY I No
LICENS
REG=MBER 1533�$Class (.'- (1
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond.—
Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forth- Power Apparatus & Large Appliances
with comply with such provisions or this permit shall be Size & Type HP, KW, KVA, or KVAR
deemed revoked.
Up to 1 Incl.
Over 1 to 10lncl.
CONTRACTORS DECLARATION Over 10 to 50 Incl.
DISTRICT NO.
PR S ED BY
'�—
FINAL
DATE I-
VALIDATIONLICENSED
FINAL
BY
r-...t
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc.
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100
ness and Professions Code, and my license is in full force and
effect.
License Number ----�.,os7Vc. Class Gw kQ
Contractor EleCtry;CalDate 3-1-81
HOME OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
ElI, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
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 (Sec. 3097, Civ. C.).
Lender's Name
Lender's Address
I certify that I have read this application and state that the
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-mgn1ioneJ4vA arty for inspection purposes.
Services
0.200 Amp, Under 600 V
201-1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Temp. Power Pole & Appurtenances
Sign with One Branch Circuit
Additional Sign Branch Circuits
Misc. Conduits & Conductors
Other (See Complete Fee Schedulel.
PERMIT FEE (Sub -Total: 90 8
PLAN CHECKING FEE (One -Fourth Permit Feel
PERMIT ISSUING FEE 8 5
TOTAL FEE 00 1 1
SEE REVERSE FOR EXPLANATORY LANGUAGE
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