HomeMy WebLinkAbout0487A (4)WORKER S'COMPEVSATION.DECLARATION 76AG6
CE -806G (280) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I 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. 3800, Lab. C.)
FOR APPLICANT TO
FILL IN
ff
t� Policy No. Compan Y"
j
New Residential Bldgs. & Pools
EACH
S
El Certified copy is hereby furnished. -
1&2-Famiiy,Sq. Ft.
O
I ❑
Certified copy is filed with the county building inspection
department.
Multi -family Sq. Ft.
Residential Swimming Pools
Date Applicant -
Outlets: Rec.—Light_ Sw.,
Class
First 20
PROCESSED BY
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CERTIFICATE OF EXEMPTION FROM WORKERS'
Total No, Additional
COMPENSATION INSURANCE
(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 No.—
I certify that in the performance of th99 work for which this
permit is issued, 1 shall note loy any tp rson fn any manner
t so as to become subject to re V s, ompensation Laws.
1'
Fixed Appliances Not Over 1 HP
Range_ Heater—D.W. _
Oven _ Dryer _ W.M.
.Date I i —4."9 ltApplicant
Top _ FAU _ W.H.
Hood _ Fan —Other—
NOTICE TO APPLICA .-lf , c'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
deemed revoked.
Size &Type HP, KW, KVA, or KVAR
Up to 1 Incl.
LICENSEDCONTRACTORS DECLARATION
Over 1 to 10 Incl-
nclLICENSED
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions ofChapter
Over 50 to 100 Inc.
9 (commencing with Section 7000) of Division 3 of the Bust-
Over 100
ness and Professions. Code, and my license is in full force and
effect.
License Number Lic, Class
Contractor Date
HOME OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031 5, Bus,
ness and Professions Code):
QI, 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
7 cer 'fy that I have read this application and state that the
ab a "'aft.. is correct. i agree to comply with all County
or ,,,anew and Slat laws regulating Electrical wiring, and
be eby authorise re r entatives of this County to enter upon
the bnve-meni bn d mperty forsinspection purposes.
i
Sig
are of Permittee Date
3—_
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 Schedule).
PERMIT FEE (Sub -Tota[)
PLAN CHECKING FEE (One -Fourth Permit Fee)
PERMIT ISSUING FEE
TOTAL FEE
SEE REVERSE FOR EXPLANATORY LANGUAGE
JOB
ADDRESS 237'
LOCALITY��' (-
NEAREST
CROSS ST C 4a
OWNER OR ("
FIRM NAME f,_
MAIL
ADDRESSc�LL%
CITY
PLANCHECK
APPLICANT
ADDRESS
CITY
ADDRESk
CITY
LICENSE OR
REG. NUMBER r�..� 7,1
DISTRICT NO. `
FINAL /
DATE
FINAL uJ• / /
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