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WORKERS'COMPENSATIONDECLARAT,ION
CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
CE-806
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.)
73—Company, �=�,T,� +� FOR APPLICANT TO FILL IN JOB d �
New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
Policy No. J
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY
Certified copy is filed with the county building inspection Multi-family Sq. Ft. NEARESTCROSS ST
department. Residential SwiPool
mming s OWNER OR
r/r / FIRM NAME ..S�C
Date Applicant Outlets: Rec Light_L Sw. ��✓d MAIL
First 20 ADDRESS � r
CERTIFICATE OF EXEMPTION FROM WORKERS' Total NO. Additional CITY Tel No.
COMPENSATION INSURANCE
PLAN CHECK 0.
(This section need not be completed if the work involved 1 APPLICANT O
by the permit is for one.hundred dollars ($100) or less.) Lighting Fixture First 20_ � ADDRESS cc
Total No. Additional 0
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 Jr _%7Z^ 04=0 O_
Oven Dryer_W.M. ADDRESS ��__ i +� N
Date Applicant Top FAU _W.H.._ 7� tE Z
Hood Fan _Other_ CITY el No. fl 7W'7
NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond. LICENSE OR d•� t�
Exemption, you should become subject to the Workers' REG.NUMBER Sy 3 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 Size&Type HP,KW, KVA,or KVAR
deemed revoked. Up to 1 Incl.
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE VALIDATION
/ /
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL F
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. Services
-A- 0-200 Amp. Under 600 V
License Number Lic.Class 201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V.
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's Additional Sign Branch Circuits
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code):
Misc.Conduits&Conductors 3 6 2 A .
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
7044, Business and Professions Code). # 0 0 0 0 o 2
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 2 -- 12 70
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) x
issued(Sec. 3097,Civ.C.)• ° ° o I 2,7 0 v e
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) O 1 3!_8 2
Lender's AddressPERMIT ISSUING FEE 7O
I certify that I have read this application and state that the TOTAL FEE / �O
above information is correct.I agree to comply with all County o
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon -�%
the a.bove•m,enKlprred-a3eo or inspection purposes
f SEE REVERSE FOR EXPLANATORY LANGUAGE
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