HomeMy Public PortalAbout5930 AVON AVE_Electrical_8/16/1989_sud panel WORKERS'COMPENSATION DECLARATION CE-806G 10i81 APP �CAMOW FOR ELECTIl' CAL PLC Rpe T
I
„hereby affirm that I have a certificate of consent to self insure, •
ora certificate of Workers' Compensation Insurance, or a.certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN - - JOB .
❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS
$ — $ LOCALITY
Certified copy'.is filed with the county' building inspection 1 & 2-Family,Sq.Ft. —
department. ,'y Multi-family Sq.Ft., '*�l„_ _,„,NEAREST /A CS/ /
CROSS
Date Applicant Residential Swimming Pools OWNER
NAMOR
E p- .,,�,
CERTIFICATE OF EXEMPTION:FROM WORKERS' Outlets:Rec Light Sw. ,: MAIL �7 �//�A
COMPENSATION INSURANCE ADDRES .6 V/K.
This section need not be com feted if the work involved b the First 20 ���
( P Y CITY p Tel.
permit is for one hundred dollars($100)or Jess.) Total No. Additional b�+
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
is issued, I shall not.employ any,person.in any manner:so as.to
become sufijectto the Workers'.Compen n Laws Lighting Fixtures First 20 ADDRESS -
�!� Additional
y�6•_ Total No. .` CITY Tel.No.
Dat 0 Applica Fixed Appliances Not Over 1 HP. PERMIT
NOTICE TO APPLICANT: If, ;aft making this rtificate of '
Exemption,you should become subject-to the Workers'Compensation Range_ Heater_ D.W. APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven Dryer — W.M._• ADDRESS
provisions or this permit shall be deemed revoked. Top FAU W.H. _
CITY. Tel.No.
LICENSED CONTRACTORS DECLARATION Hood Fan Other_
I hereby affirm.that I am licensed under provisions of Chapter 9 Dlsp — Room Air Cond. LICENSE OR
(commencing with Section 70100) of.Division'3 of the Business and REG.NUMBER Class.
Professions Code,and my4license is in full force and effect. DISTRICT NO. PROCESS
Power Apparatus& Large Appliances- O� a
Size& Type HP,KW,KVA,or KVAR S p
License Number Lic.Class Up to 1 incl FINAL
U
Over 1 to 10 Incl. DATE Z VALIDATION
-ContractorDate ”- Over 10 to 50 Incl. 0
❑ FINAL
lam exempt under Sec. Over 50 to 100 Inc. y
B a
B.&P.C.for this reason Over 100 ' Cf)
Services, Swbd.,MCC& Panelboards �.
Date: 0-200 Amp.Under 600 V e�
Signature 201- 1000 Amp:Under 600 V
Over 1000 Amp.or-Over 600 V
Exemption for,Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole'& Appurtenances 7
HOME OWNER-BUILDER,:DECLARATION Sign with One Branoh Circuit a
I hereby affirm that I am exempt from the Contractor's License Law ACCT.V
for the following reason(Section,7031.5, Business and Professions Additional Sign Branch Circuits ,
rt .•�
Code):'.' 3307 25.SO
LJ I,as own Misc.Conduits& Conductor's TTY
owner of the property,�will do the work and the structure 1 ITEMS
11
t�
3
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ,1
and Professions Code).' '. TOTAL 2�a 50
CONSTRUCTION.LENDING AGENCY CHECK
I hereby affirm that there is_a construction lending agency for the CHANGE
performance of the work for which this permit,is issued(Sec.3097, PERMIT FEE (Sub-Total) nuV
Civ.C.).
PLAWCHECKING FEE Ot�00-€l001
Lender's Name 8116l$9
PERMIT ISSUING FEE
_ C��u car 413.
Lender's Address_ !"'
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and, State laws regulating Electrical wiring, and hereby authorize
represen sof this County o enter upon the above-mentioned
property for i spe n purpo as.
SEE REVERSE FOR EXPLANATORY LANGUAGE a
I re of Permittee Date