HomeMy Public PortalAbout4906AGNES AVE_Electrical (10) iWORKERS' COMPENSATION DECLARATION CE-806 10i81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that 11hae' ` certificate of consent to self CE-806G
insure, or a sErlificaP�of V o�rkers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certi?iei copy thereof (Sec. 3800, Lab. C.)
Policy No._------, _Company FOR APPLICANT TO FILL IN JOB pj
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
Certified copy is filed with the county buil 9 insp 1 & 2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. NEAREST
CROSS SAAA- Residential Swimming Pools OWNER T
Date ; .. Appli ant
IIyy FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Recy„C_Lighl�Sw._� MAIL
COMPENSATION INSURANCE ADDRESS
First 20
(This section need not be completed if the work involved by Total No. Additional CIT Tel.
the permit is for one hundred dollars ($100)or less.) PLA CHE
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I certify that in the performance of the work for which this APPLICA
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 r
Total No. Additional Cl Y
Date Applicant Fixed Appliances Not Over 1 HP PERM
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
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBERClass.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect. Power Apparatus & Large Appliances /� 0
47 11, Size &Type HP, KW, KVA, or KVAR' 561 U
License Numbe Lic. Class Up to 1 Incl. FINAL
Over 1 to 10 Incl DATE —���� 4ALIDATION Off,
Contractor r Date CS
❑ Over 10 to 50 Incl. MVIZ,eZ
Ld
I am exempt under Sec. Over 50 to 100 Inc. a
Over 100
B.&P.C. for this reason _
Date: Services, Swbd., MCC& Ponelboards
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp, or Over 600 V
SINGLE FAMILY Temp. Power Pole& Appurtenances r
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit z 6 5 5 0 A
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits #,o,o o o 0 2
Professions Code): 0 0 1 0 0
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)— ► o 0 0 1 a 0 0;9
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY .0220-87
1 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
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby out horiz represent es of is County to enter upon
the above-me ned pr ty for spection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date