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WORKERS'CD51F'ENSATIONDECLARATION 76A663 APPLICATION FOR ELE�TRICAL PERMIT � j
CE-806G(2�80)
t hereby atfirm that [ have a certi�cate of consent to sclf COUNTY OF LOS ANGELES ��- BUILDING AND SAFETY !
insure,or a certificate of Worken'Compensation Insurance,or �• �
a certified copy thereof(Sec.3800,Lab.C.)- - �
FOR APPLICANT TO FILL IN Jpg . / ��
� Pollcy No. Company ADDRESS L
. N¢w Residential Bldgs.&Pools EACH NO. FEE j
� Certified copy is hereby furnished. 1&2-Family,Sq,Ft, s — s LOCALITY � G (
❑ Multi•tamily Sq.Ft. — NEA 7 �
Certified copy is filed with the county building inspectinn CHOSS ST Qi�J�I
Residential Swim ing Pools 3
deparimenL �(�G p�qMENAME � " i
�
Date Applicant ' Outlets:ReG�L�g Sw._ � qpDRESS / C1 � j
S First 20
CLRTiFICATG OP EXLh1PTION iROM WORKERS' Total No. Additional CiTV �f-Tei No.r`� � rT �� 1,
COAIPENSA7ION INSURANCC . � PLAN CHECK � • O ;
APPLICANT p
(This section need not be compieted if the work involved . U
by the permit is for one hundreA dollars (5100)or less.) Lighting Fixtures First 20 �' . � �
ADDRESS
• Additional
1 certify thxt in the petformance of the work fnr whlch this F zed Appliances Not Over i HP CITY Tel No. �
permit is issued,I shall not employ any person in any manner pEHMIT w
so as to hecome subject t ihe Wo GG��'ComPensalion La�vs. Range_Heater D.W,_ APPLICANT��;��� a
\\ Oven _Dryer_W.M._ A�DRESS N
Date���APPlicant ��� ToP _FAU _W.H.._. z .
� Hood_Fan _Othar— CITv rei No. ,
NOTIC,&TO APPLICAN7:if,after makin6 this CerHficste ot pi5p. �ROom Aif COnd.� LICENSE OR
Gzemption, you should become suM1ject to the 11'orkers' REG.NUMBER Cleys
Compensatinrf provisions nP the Labo�Code,you must for[h• power Apparatus&Large Applie�[es � OISTRICT NO. PROCESSED Bv
wilh comply with such Provisions or this�permit shall be - Size&Type HP,KW,KVA,or KVAR -�
deemed revoked. �Q ��j,�,�,p�r�
_ � Up to 1 Intl. -
OVef 1 to 10 Inel. oATE �
LICENSFD CONTRACTORS DECLARATiON Over 10 to 50 Incl. � � ��.�. �.. VALIpATION �
1 hereby affirm Ihat I am licensed under provisions of Chapter Over SO to 100 Inc. FiNAI. � �
9(commencing with Section 7000)of Division 3 of the Ausi- Ove�100 - BY �
ness and Prnfessions Cnde,and my license it in full force and �' � .
effect Services � � - � �
License Numher � � Lic.Class 0-200 Amp,Under 600 V
201-1000 Amp.Under 600 V , .
Contracmr Date Over 1000 Amp.or Over 600 V . ' •
�HO\1F.OWNER•BUILDER DECLARATION Temp.Power Pole&Appurrenances �
1 hereby affirm that I am ezempt from the Contractor's Sign with One Branch Circuit - . '
License Law for the foilowing reason(Section 703I.5,Busi• Additional Sign Breneh Cireuits �
�10.1,9A
na;a,;u'Pwfrssions Code): � . ,
Misa Conduits&Conductars � ,
� I,as owner ot the propeny,will do ihe work and the Other(See Complete Fee 5chedule)— - #����� i 2
structure is not intended m offered for sale (Set�ion ' - ��� �2 a 5�
70C4,Business and Professions Code). .
CONSTRUCTfON LF,NDING AOL•NCY � . z�5 0= ��
I here6y affirm that there is a construction Irnding agency , .��• • c.i �
for the perlormance uf the work for+vhich Ihis perrnit �s pERMIT FEE (Sub•Total) /� �
issued(Sec.3097,Civ.C.). � (2� 5,'.-B;� j
Lender's Name pLAN CHECKING FEE (One•Fourth Permit Fee) ' �
Lender's Address� � PERMIT ISSUING FEE �. ' y� - � �
1 ttrtify that f have read�his application and state that the TOTAL FEE ' � . .
above informetion is correct.[agree fo comply with a�l Coimty !;
i rdinanCet and tate I ws regulating Electrical wiring, and � i !� � � �
reby thorize r res atives of this Cuunty to ente�upon - � � � !
1 eb titione ro rry for inspection purposes. SBE'REVERSB FOR E•XPLANATORY LANGUAGE � � �
. Signalure of Permiqee � Da� , � �
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