HomeMy Public PortalAbout5745 AGNES AVE_Electrical__ 0 K)IWORKERS'COMPENSATIONDECLARATION
CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
CE-806
Whereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensati n Insurance,pf
a certified cop t reec. 3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB
Policy o. Company New Residential Bldgs.&PoolsEACH NO. FEE ADDRESS
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY �
Multi-family Sq. Ft. — NEAREST
JRCertified copy is filed with the county building inspecti� CROSS ST
department. Residential Swimming Pools OWNER O
FIRM NAME
Date Applicant Outlets: RecLight ?� Sw. '�� ty MAIL l � ,
nn�� First 20
CERTIFICATE OF EXEMPTION FROM W KERS' Total No.'" Additional CITYTel No. G }
COMPENSATION INSURANCE PLAN HECK d
APPLICANT O
(This section need not be completed if the work involved U -
Lighting Fixtures First 20
by the permit is for one hundred dollars ($100) or less.) Additional ADDRESS
Total No.
0 O
t
I certify that in the performance of the work for which this CITY Tel No.
permit is issued, I shall not employ any person iFixed Appliances Not Over 1 HP
n any mannerPERMIT W
so as to become subject to the Workers' Compensation Laws. Rang .Heater_D.W. , APPLICANT
Range. d
Oven Dryers W.M._ ADDRESS. '�' N
Date Applicant Top FAU _W.H..
Hood Fan CK Other_ t. CITYTel No.,<-�V
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond,_ � LICE
O
Exemption, you should become subject to the Workers' REG. NUMBER �'� lass
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. °
FINAL
Over 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION er 10 to 50 Incl.• ?—z y VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 9nc. FINAL Q
9 ,(commencing with Section 7000) of Division 3 of the Busi- Over 100 BY �-�"�
ness and Professions.Code, and my license is in full force and
effect. y+D Services
License Number ���'� Lia Class_ C3 I 0-200 Amp. Under 600 V
/ 201-1000 mp. nder 600 V
Contractor Ahleeaq emg Date ` 9 Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances -5 8 6 7 4 A
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit o:o o o o 2
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code): 2,00 ']5,0 0
Misc.Conduits&Conductors
I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— ° ° ° 7 J. 0 0�
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 0 2 0 3—8 4
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 l {J
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 inspec!�on purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
¢ '? .7 —X Y -
Signature of Permittee Date