HomeMy Public PortalAbout6159 AVON AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.) fl '
Policy No. Company FOR APPLICANT TO FILL IN JOB �('_
�
❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools
EACH NO. FEE ADDRESS ($ q LfLlfj V�
❑ Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ — $ LOCALITY
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL ``f
COMPENSATION INSURANCE ADDRESS moo LA qi
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars ($100)or less.) Total No. Additional CITY Tel.No. 49
-'I4
I certify that in the performance of the work for which this permit PLAN RECK
APPLICANT
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 Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M.— ADDRESS �Q)
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. � �•.�
LICENSED CONTRACTORS DECLARATION Hood — Fan _ OtherCITY
_ 'Ytily GIL
T81. 4 S ! V
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. — Room Air Cond. REG.NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. DISTRICT NO. PRO D BY
Power Apparatus& Large Appliances 15;�- I�� � Size& Type HP,KW,KVA,or KVAR
License Number G r Lic.Class ~, U Up to 1 Incl. FINAL V
Over 1 to 10 Incl. DATE VALIDATION
Contractor Date Over 10 to 50 Incl. V
❑ FINAL
lam exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 CL
( Services,Swbd.,MCC& Panelboards I ® Z
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V
❑ Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp. Power Pole& Appurtenances
HOME� OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law gdditionai'Sign Branch Circuits rf
for the following reason (Section 7031.5, Business and Professions
i Code):
❑ Misc.'Conduits & Conductors °a
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 307 31°Or f
jand Professions Code). ® iTE
CONSTRUCTION LENDING AGENCY TOTAL 31 - 00
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) CH0L•K 31.00
Civ. C.).
PLAN CHECKING FEE CHANGE
Lender's Name
PERMIT ISSUING FEE I!I}[jl' I �EIi 5 j
Lender's Address +
9/90
1 certify that I have read this application and state that the above TOTAL FEE ® �� i
�I.io -4510
information is correct. I agree to comply with all County ordinances
i and State laws regulating Electrical wiring, and hereby authorize
I represent Ives is County to enter upon the a ove- ntioned
property r inspecti urposes.
I SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa o e ee ate