HomeMy Public PortalAbout10103 BOGUE ST_Electrical_7/30/1985 • 3•
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. CE-806 WORKERS' COMPENSATION DECLARATION 10/61 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G ,
"insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800, Lab C )
Policy No',1_0 Company, �N 1T1 FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs. & Pools EACH NO FEE ADDRESS (�
Certified copy is filed with-the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITYCM&LOCALITYe G
tion department .Multi-family Sq Ft. — NEAREST
t� p �L?� 0� Residential Swimming Pools CROSS ST LIjCtJ
Date r! vV� Appl scant J-1ur OWNER OR
FIRM NAME O AI
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light Sw. 'MAIL
COMPENSATION INSURANCE ADDRESS Qyj G V e
(Thitid t b
s section neenot completed if the work involved b First 20
p Y Total No Additional CIT ,e Ct"� Tel.
the permit is for one hundred dollars ($100)or less.)
I certifythat in the performance of the work for which this PLAN CHECK
P 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 Applicant Fixed Appliances Not Over 1 HP PERMIT C `
NOTICE TO APPLICANT:' If, after making this Certificate of APPLICANT -�� �/V G 4�e +•
Exemption, you should become subject to the Workers' Range_ Heater_D.W
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer W.M.— ADDRESS iD D-(�� LL
with comply with such provisions or this permit shall be Top — FAU W.H. — 3,kso 3
deemed revoked Hood Fan _ Other_ CITY If Q VI Tel. N1340
LICENSED CONTRACTORS DECLARATION LICENS OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond REG NUMBER 4ks-,-A Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCES BY
and Professions Code, and my license is in full force and effect Power Apparatus& Large Appliances �` /]� d
'L - ' Size &Type HP, KW, KVA, or KVAR (f Q
License Number�OO j6f� Lic Class _✓ Up to 1 Incl FINAL �p j �eZ��i/� V
f� �+ 1129
31LZ',Over 1 to 10 Incl. a DATE y _ r� a 1.r 0
ContractodN / +Date v 'MVV'' L� VA ATION Q
❑ Over 10 to 50 Incl FINAL V
I am exempt under Sec Over 50 to 100 Inc. BY
IL
B.&P.C. for this reason Over 100 Z
Date Services, Swbd , MCC & Pandlboards
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V 2 5 7, A
ElExemption
1000 Amp or Over 600 V
Exemption for Reg. Maint. Elect # o,o 0 0 0 2 '
SINGLE FAMILY Temp. Power Pole&Appurtenances !I-- 0
HOME OWNER-BUILDER DECLARATION 21.00
- Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits o 0 0 2 Q Q
Law for the following reason (Section 7031.5, Business and
Professions Code). .07.3.0-85
El1, as owner of the'property, will do the,work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY t
I hereby affirm that there is a construction lending agency for
theerformance of the work for which this permit is issued PERMIT FEE
p p (Sub-Total)
(Sec. 3097, Civ C )
PLAN CHECKING FEE 0 4Z -
Lender's Name
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-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
7- .216
Signature of Permittee Date