HomeMy Public PortalAbout5946 AVON AVE_Electrical_2/2/1983_HVAC other WORKERS'COMPENSATIONDECLARATION APPL'IC.ATION FOR ELECTRICAL PERMIT.
CE-806
f "111 CE-806G (2-801 +
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, La . .)
FOR APPLICANT TO FILL IN ,JOB
Policy No. Company New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY --a. g
Multi-family Sq. Ft. NEAREST r
�—
Certified copy is filed with the county b 'd g inspection CROSS ST
department. Residential Swimming Pools OWNER OR
/'� FIRM NAME
Date—Llss;FApplicant .Outlets: Rec.—Light_Sw. MAIL (�9 ,/
First 20 ADDRE S J Co www "w
CERTIFICATE OF EXEMPTION FROM WORK S' Total No. Additional CIT Tel No.
COMPENSATION INSURANCE d
PLA CHECK O
(This section need not be completed if the work involved APPLICANT U
by the permit is for one hundred dollars (5100) or less.) Lighting Fixtures First 20 ADDRESS
Additional
Total No. O
1 certify that in the performance of the work for which this CITY Tel No.
permit is issued, I shall not employ any person in any manner Fixed Appliances Not Over 1 HP U
PERMIT
so as to become subject to the Workers' Compensation Laws. Range_Heater_D.W. APPLICANT d
Oven _ Dryer_W.M._ ADDRESS
Z
Date Applicant Top " _ FAU _W.H.._ y 7a
Hood _ Fan —Other CITY 9 Tel No.•
NOTICE TO APPLICANT: If, after making this Certificate of. Disp. _ Room Air Con,d LICENSE O
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW, KVA,or KVAR l v
Up to.1 Incl.
FINAL /
Over 1 to 10 Inc). DATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL t
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 1 /�-
effect. ^ y� Services
License Nuritbe Lic.Class- C_`1C./ 0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V l l d y
HOME O UI DER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit pp� o
Additional Sign Branch Circuits V /'{V}+ �952.3 A
License Law for the following reason (Section 7031.5, Busi- y�
ness and Professions Code): 2. {Yt'/• (� #f�o 0,00,0
Misc.Conduits&Conductors � ;(JIVI
1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 2 0 ° [�0
structure is not intended or offered for sale (Section V
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY ;°to ° 1 0 0,0M
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) 2, 2—$•3
issued (Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Feel
Lender's Address PERMIT ISSUING FEE A-)
1 certify that I have read this application and state that the TOTAL FEE C/above information is correct.I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize represe ives of this County to enter upon
the above- entioned pr er y for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
a
/f������
Si atu of Permittee D to