HomeMy Public PortalAbout4902 ARDEN DR_Electrical__ WORKERS'COMPENSATION DECLARATION 76- 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT
hafet:y`affirm that I have a certificate of consent to self insure, 8o6
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS r
E] Certifiedcopy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE
❑ 1 & 2-Family,S Ft. LOCALITY
Certified copy is filed with the county building inspection y� q� $ — $
department. Multi-family Sq.Ft. — NEAREST
CROSS ST.
Date Applicant
Residential Swimming Pools OWNER OR
• FIRM NAME /
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
Outlets:Rec— Light Sw.
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20
. Additional CITY I.N
Total No
permit is for one,hundred dollars($100)or less.)
I certify that in the performance of the work r which this permit PLAN CHECK
is issued, I shall not employ anAPPLICANT /
p y y perso ;a , ner so a+s to
become subject to the Workers'Com ns dos. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel.No.
Date — Applica t ixed Appliances Not Over 1 HPNOT E TO APPLICANT: If, a akinhisCertificate ofPERMIT
Exemption,you should become subje to the ers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top FAU W.H.
CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER Class.
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROC ED Y' }
Size& Type HP, KW,KVA,or KVAR Guu Q
License Number Lic. Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl.
DATE VALIDAT N Ir
Contractor Date
Over 10 to 50 Incl. V
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 N
Services,Swbd.,MCC& Panelboards /) ® Z
Date:
0- 200 Amp.Under 600 V V
Signature 201 - 1000 Amp.Under 600 V
❑
Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V �6 8 22 A
SINGLE FAMILY Temp. Power Pole& Appurtenances # 0 0 0 0 0 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law 0 - 2S50
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): o o -2 5 5,0 v
I,as owner of the property,will do the work and the structure Misc.Conduits & Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ► 1I..0 7-8 7
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, PERMIT FEE (Sub-Total)
Civ.C.).
PLAN CHECKING FEE
Lender's Name +
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL FEES
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
repre a i e f this County to enter upon the above-mentioned
pr ert fo nspecti n purposes.� SEE REVERSE FOR EXPLANATORY LANGUAGE
ign ure of Per ittee Dat