HomeMy Public PortalAbout5806 AGNES AVE_Electrical__ RKERS' COMPENSATION ^ECLAGATION :.-. 76A663' 10/81
CE_806G (APPLICATION FOR• ELECTRICAL PERMIT
I .ieFeby affirm that I,have a certificate of consent o self CE-806
I insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
j Policy No. Company FOR APPLICANT TO FILL IN JOB '
❑ Certified copy is hereby furnished. New Residential Bldgs. &'Pools EACH NO. FEE ADDRESS
I ❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq Ft. $ $ LOCALITY
tion department. Multi-family Sq. I CROSS ST. W C/
i Residential Swimming Pools
I Date Applicant OWNER OR
i s¢� 'n FIRM NAME i �3a L1 N L C,
%
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec%J Light�Sw:� MAIL
COMPENSATION INSURANCE 3 v ADDRESS es L!r."
This section need not be com leted if the work involved b First 20 w , C
( p Y Total,No. Additional CITY �' Tel. No.
the permit is for one hundred dollars ($100) or less.)
PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to-the Workers' Compensation Laws. Lighting Fixtures First 20 ADDRESS
@ Total No.�_ Additional CITY Tel. No.
Date i2' v Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making thi erti ' ate of ; APPLICANT
i Exemption, you should become subject t the orkers' Range_ Heater._D.W.
Compensation provisions of the Labor Code, you must forth- Oven _ Dryerl W.M.— ADDRESS J t
with comply with such provisions or this permit shall be Top _ FAU I W.H.
Other—
LICENSED CONTRACTORS DECLARATION 1 3 CITY Tel. No.
deemed revoked. � �j3- �
Hood Fan _ 6 LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG, NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business ( DISTRICT NO. PROC E BY
and Professions Code, and my license is in full force and effect. Power Apparatus 8�Large Appliances _ /)
Q �y Size & Type HP, KW, KVA, or KVAR• L L/ O
License Number ` �4 O Lic. Class _ U to 1 Incl. FINAL �} V
Over 1 to 10 Incl. DATE/ —'_�5 /� VALIDATI
iContractor ate Over 10 to 50 Incl. FINAL /✓d� V
LU
❑ I am exempt under Sec. Over 50 to 100 Inc. ' B / Q� 1/ Nf
CL
B.&P.C. for this reason
Over 100
Date: Services, Swbd. MCC& Ponelboords
200 Amp. Under 600
Signature 2 1000 Amp.i Un er 600 V OV A a
❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V i '� 0 0 0 0 0 2
SINGLE FAMILY
Temp. Power Pole;&Appurtenances .( - 57, 75
HOME OWNER-BUILDER DECLARATION Sign With One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License I s
Law for the following reason (Section 7031.5, Business and Additional Sign Bronch Circuits o 0 0 5 ],7 5 L
Professions Code):
01
❑. I, as owner of the property, will do the work and the Misc. Conduits &Conductors ( 1' —84
structureis not intended or offered for sale (Section Other (See Complete Fee Schedule)_
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 PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE D
Lender's Name I
PERMIT ISSUING FEE
Lender's Address
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-mentio d property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature erm a Date
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