HomeMy WebLinkAbout1265A WORKF.RS��o�+PENSATioNDE��ARAT�aN �� �6A663 .APPLICATION FOR ELECTRICAL PERMIT . � � � .
CE-806G(2�80)
1 here6y affirm Ihat 1 have a cer�ificaie o(consent ro selt COUNTY OF LOS ANGELES BUILDING AND SAPETY
insure,or a certificate nF Workers'Compensation Insurence,or - �
a certiCed�c,popy Ath'er`epof(Sec.3800 ab.CJ
��vpO—�-�1 DY,�./� FOR APPLICANT TO FILL IN Jpg �
� , Policy No. Company ADDiiESS
� � New Residential Bldgs.&Pools- EaCH NO. FEE
ertified copy is herehy fumished. 1&2•Family,Sq.Ft. $ — g LOCAL�TY D �
� Multi-family Sq.Ft. NE.4RE T
� Certified copy is filed with the c unty buil 'ig in ction CROSS ST ' -
department. Residential Swimming Pools OWnIER OR
�,, ���� FIFM NAME _
DatrL ��Applicant Outlets:Rec_Light_Sw._ aDDRESS
First 20
CERTIFICATG OP EJ(EhiPTION FRO'd WORKERS' Total No. Additional� CITY Tel No. }
; COMPGNSATION INSllRANCI - P�qN CHECK a
(This section need not be completed i(the work invo�ved APPLICANT �
by the permit is for one hundred dollars(3100)or less.) Lighting Fixmres firat 20 ADDHESS
Additional �
1 certify that in the performance of the work for which this Fi�ced Appliances Not Over 1 HP � � CITY � 7e1 No. �
permit is issued.i shali not employ any person in any manner� PERMIT �. W
so as to become subject to the Workers'Compensatfon Laws. Range_Heatef_D.W. APPUCANT� p.
- . Oven -_Dryer_W.M._ ADDFESS � Z
- Date Applicant Top- _FAU _W,H._ � � � —
Hood_Fan _Other— CIrY �ji,� Te1 No.
' �NOTICE TO APPLICANT:If,after making ihis CerliCcate of Disp. _Room Air Cond._ �LICENSE OR
Exemption,�you should bernme su6ject [o the Workers' AEG.NUMBER Z� �lass ,
Compencatfon provisions of the Labor Code,you must f�rth- Power Apparatus&Large ApplianCeS DIS7FICT NO. PROCESSED BV .
with comO�Y with such provisions or this permit shall be � � -
. deemed revoked. Size&Type HP,KW,KVA,or KVAR `O
Up to 1 Incl.
FINAL
� Over 1 Co 10 Inel. DATE �
LICENSiiD CONTRACTORS DECLARATION � Over 10 to 50 Incl. C�/oZ�� ,�� VAII DATI ON •
7 here6y affirm that I nm�icensed under provisionsof Chaptrr Over 50to 1001na FINAL �j '
9(commencing wi[h Section.7000)oC Oivision 3 of the Rusi- � Over 100 Bv r'��,Y('�� '
ne5s and Professions.Code,and my�icense is in full force and � � .
effect. � Services . .
License Numberl�L�Lic.Clasx 0•200 Amp.Under 600 V � �
� ��� 201•1000 Amp.Under 600 V
Contractor�"�Il.���11rl.ri Date Over 1000 Amp,Or Over 600 V . '
IfOME OR'NER•BUILDER DECLARATiON � Temp.Power Pole&Appurtenances � �
I hereby affirm that I am ezempt Crom the Contractor's Sign with One Braneh Circuit . . � .
License Law tor Ihe followin¢reason lSedion 7031.5,Rusi• pdditional Sign Branth CirCuitS .
ness and Profasions Code): �
Mise.Conduits&Conductors � �� 2 6 5 A .
� 1, as owner of Ihe property,�vi�l do the work and the Other(See Complete Fee Schedulel— � � .
structure is not intended or offercd for sale (Section � #� � � � �2
7044,Business and Professions Code). - �
�CONSTRUCTION LLNDING AQENCY . . - I • •2 Q Jr O �
1 hereby affirm fhat ihere is a construnion lending agency
for the performance of the work tor which this permit is pEAMIT FEE �(Su6-Total) • • •2 Q 5�� �
issued(Sec.3097,Civ.C.). � . �
Lender's Name PLAN CHECKING FEE (One•Fourth Permit Fee) ���..� 3=fj z
Lender's Address PERMIT ISSUING FEE � - �
1 certify that I have read this spplication and state that ihe TOTAL FEE . � �
abore information is correct.f agree to comply with all County , . - .
ordinsnces and State laws regulating L•lectrical wiring, and - -
here6y auth ize representa[' s of dris CouMy to enter upnn , .
t a qv.- n'oned oper y r i p ction purposes. -
SEG�REVERSE POR BXPLANATORY LANGUAGE , .
� 12 lS'`� .
� Signature of Permittee Date � � , �
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