HomeMy WebLinkAboutNo Permit Number (41)4OLY f- y
WORKERS'COMPENSATIONDECLARAT[ON APPLICATION FOR ELECTRICAL PERMITCE-806G (2-80) CE-806
i hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY Ll
insure, or a certificate of Workers' Compensation Insurance, or
a certified copy thereof (Sec. 3900, Lab. C.)
FOR APPLICANT TO FILL IN OB
Policy No. Company
New Residential Bldgs. &Pools EACH NO. FEE ADDRESS 342
C1 Certified copy is hereby furnished. i & 2-Family,Sq. Ft. $ —' $ LOCALITY
Certified copy is filed with the county building inspection Multi-family Sq. Ft. — NEARESTCROSSST
department. Residential Swimming Pools OWNER OR
FIRMNAME
Date Applicant Outlets: Rec._Light_ Sw.--/—MAIL6First20ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No.
COMPENSATION INSURANCE
PLAN CHECK d
This section need not be completed if the work involved
APPLICANT OUbythepermitisforonehundreddollars ($100) or less.) Lighting Fixtures First 20 ADDRESS
Additio
Total No.
pliances1certifythatintheperformanceoftheworkforwhichthisFixedAppliances Not Over 1 HP
CITY - Tel No. Opermitisissued, I shall not employ any person in any manner PERMIT
so as to become subject to the Workers' Compensation Laws. Range_ Heater—D.W. _ APPLICANT W
Oven _ Dryer _ W.M. _AppRESS N
Date Applicant Top _ FAU _W.H.,_ Z
Hood _Fan ,-_Other_ CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond.— LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus & Large Appliances DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be
deemed revoked. Size & Type HP, KW, KVA, or KVAR
Up to 1 Incl.
Over 1 to 10 Incl.
FINAL
DATEVALIDATIONLICENSEDCONTRACTORSDECLARATIONOver10to50Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINALIAL
BY r r t ^.
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. Services
License Number Lic. Class
0-200 Amp. Under 600 V 0 `i 1 .
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp. or Over 600 V O
qv2
HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances 40_
a —
I hereby affirm that I am exempt from the Contractor's Sign
Addiwith
One Branch Circuit
tional Sign Branch CircuitsLicenseLawforthefollowingreason (Section 7031.5, Busi-
ness and Professions Code):
I, as owner of the do the the
Misc. Conduits & Conductors
property, will work and
structure is not intended or offered for sale (Section
Other (See Complete Fee Schedu lel—
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 PERMIT FEE (Sub-Total) issued (Sec. 3097, Civ. C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
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-mentioned property for inspection
SEE REVERSE FOR EXPLANATORY LANGUAGE
1purpose
i to of Permittee ate
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NWN"NMuM WCL&WA=01
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