HomeMy Public PortalAbout10144, 10128 BOGUE ST_Electrical_11/11/1981 WORKER S'COMPENSATION DECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT
CE-806G (2-80)
I hereby affirm that I have a certificate of consent to self, COUNTY OF LOS ANGELES �� BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C'.)) 7�)
Policy No. Company ✓ T ' 4 4 �' FOR APPLICANT TO EACH N NO FEE ADDRESS. (i/
New Residential Bldgs. &Pools
❑ Certified copy,is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY L
Multi-family Sq. Ft CROSSST
Certified copy is filed with the county building inspection Residential Swimming Pools i
department. OWNER OR
FIRM NAME L /.r',' or-
Date Applicant 05C 1-1v C Outlets. Rec-_ Light Sw MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY '� � f'C /i C_I/ el No
- COMPENSATION INSURANCE PLAN CHECK d
APPLICANT O
(This section need not be completed if the work involved Lighting Fixtured First 20 V
by the permit is for one-hundred dollars ($100) or less.) ADDRESS
Additional cc
Total No.I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No.
permit is issued, I shall not employ any person in any manner PERMIT W
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT (i/G Lr�/ p.
Oven Dryer_W.M. ADDRESS' O (�_ `L Z
Date Applicant Top _ FAU _W.H.
Hood — Fan —Other— CITY _^Tel No. • 5/
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond.— LICENSE OR ^^�� O�/ G_
Exemption, you should 'become subject to the Workers' REG. NUM B E R �c �'� Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances. DISTRICT NO. POMESIAD BY
with comply with such provisions or•this permit shall be Size&Type HP, KW, KVA,or KVAR
deemed revoked.
- - Up to 1 Incl.
L
Over 1 to 10 Incl. DATE r
LICENSED CONTRACTORS DECLARATION Z4 VALIDATION
Over 10 to 50 Incl. .
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
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. 9 Services
License Number nZ J _,3�Q 13Lic.Class �r 0-200 Amp. Under 600 V
201-1000 Amp'. Under 600 V
Contractor D to� w O Over 1000'Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm .that I am exempt.from the Contractor's Sign with One Branch Circuit l
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
7 ness and Professions Code):
❑ Misc.Conduits&Conductors /L Z
1, as owner of the property', will do the work and the Other (See Complete Fee Schedule)— �Y .`C
structure is not intended or offered for sale (Section /Vv
7044, Business•and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 01 �Y
for ttie performance of the work fog 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
I certify that I have read this application and state that the TOTAL FEE
. )I'A
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 propertp for inspection purposes. SEE RE ER •LANAORY LANGUAGE
valm' .1i /n
Signature of Permittee 'Date