HomeMy Public PortalAbout4835AGNES AVE_Electrical (10) WORKERS' COMPENSATION DECLARATION CE-806 10181 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. Company 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. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw. MAIL
COMPENSATION INSURANCE ADDRESS
This section neenot be completed if the work involved b First 20
( tid p y Total No.— Additional CITY Tel. No.
the permit is for one hundred dollars ($100) or less.)
PLAN CHECK
I certify that in the performance of the work for which this 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
TAdditional
Total No.
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
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
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. Hood Fan _ Other_ CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR a
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class. C)
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY U
and Professions Code,and my license is in full force and effect. LU
Size & Type HP, KW, KVA, or KVAR J
License Number Lic. Class Up to 1 Incl. FINAL
DATE
Over 1 to 10 Incl. VALIDATION }
Contractor Date a Over 10 to 50 Incl. FINAL 0
I am exempt under Sec. Over 50 to 100 Inc. BY 0
B.&P.C. for this reason Over 100
Services, Swbd., MCC & Panelboards Ld
Date: 0 - 200 Amp. Under 600 V ► E-
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V I
SINGLE FAMILY Temp. Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION �.
Sign with One Branch Circuit ,, •.�
I hereby affirm that I am exempt from the Contractor's License Additional n Branch Circuits
Si 1
Law for the following reason (Section 7031.5, Business and g
Professions Code):
j Misc. Conduits& Conductors
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE n
above information is correct. I agree to comply with all County c
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
rSignature of Permittee Date