HomeMy Public PortalAbout6219 AVON AVE_Electrical__ WORKERS COMPENSATION DECLARATION \ CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
I her4y affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES J, —Z�-tll�DING AND SAFETY
insure or a certificate of Workers Co ensation in ce or
�7t,
Zoo
�thereof(Sec 3800
6�'i'� FOR APPLICANT TO FILL IN SOB
oli Compan EACH NO FEE ADDRESS
af pp New Residential Bldgs & Pools
Certified copy is hereby furnished /'�O� 1 &2 Family Scl Ft $ — $ LOCALIY
r Multi family Scl Ft NEAREST
Certified copy is filed with the coup y budding inspection CROSS ST
department a Residential Swimming Pools OWNER OR
/ FIRM NAME 'yl
Date�0Applican Outlets Rec Light Sw gDDRESS J
First 20 _ ��
CERTIFICATE OF EXEMPTION FROM WORKERS ' Total No Additional CITY Tel No �
COMPENSATION INSURANCE PLAN CHECK d.
(This section need not be completed if the work involved APPLICANT 0
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS 0
Total No Additional
cc
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No 0
permit is issued I shall not employ any person in any manner WE U
so as to become subject to the Workers Compensation Laws Range_ Heater D W APPLICANT W
Oven _ Dryer_W M ADDRESS 0.
7 ato
Date Applicant Top _ FAU _W H Z
Hood Fan _Other_ CITY d Tel No -6-- 3
NOTICE TO APPLICANT If after making this Certificate of Disp Room Air Cond_ LICENSE OR �D C
Exemption you should become subject to the Workers 611,EG NUMBER lass
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NOC SED BY
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVAR J
deemed revoked
Up to 1 Incl
Over 1 to 10 Incl ` FIN EL 61-1
Z _
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl �3 8 VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
9 (commencing with Section 7000) of Division r3 of the Busi I Over 100 BY
ness and Professions Code and my license is in full force and
effect Services
License Number2h 0.1 Lic Class 0/b 0 200 Amp Under 600 V 7
` 201 1000 Amp Under 600 V /
Contractor�����L 6,/CDate /��0 Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits _
ness and Professions Code)
Misc Conduits&Conductors
I as owner of the property will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section ;929&8A
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY # 0 0 0 0 o 2
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) i2 0 - 2650
issued (Sec 3097 Civ C )
Lender s Name PLAN CHECKING FEE (One Fourth Permit Feel 0 0 0 2 6 5 0 c=i
Lender s Address PERMIT ISSUING FEE 1 0,7-80
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 authoriz,0 representatives of this County to enter upon
17noned property for ins ion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa re of Permittee Date