HomeMy Public PortalAbout5233ALESSANDRO AVE_Electrical (2) WORKER S'COMPENSATION DECLARATION
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 ANGELES61 BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab. C.)
FOR APPLICANT TO FILL IN JOB ��� Nv J
Policy No. Company EACH NO. FEE ADDRESS
New Residential Bldgs.&Pools
❑ Certified copy is hereby furnished. 1 &2-FamilY. q•S Ft. $ — $ LOCALITY �\
❑ Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department. Residential Swimming Pools 1Q.1A4-cR-e'R -
FIRM NAME
Date Applicant Outlets: Rec.13Light Sw. a ADDRE
CERTIFICATE OF EXEMPTION FROM WORKERS' First io J
COMPENSATION INSURANCE Total No. Additional %3 CITY Tel No. }
• PLAN CHEC d
APPLICANTO
(This section need not be completed if the work'involvedSp Q U
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS
Additional cr
1 certify that in the performance of the work for which this Total No. CITY Tel No. F-
FixIx _Ix ed Appliances Not Over 1 HP
permit is issued, I shall not a ny person in any manner PERM LT
LLJ
so as to become subject to th orke ' Com ensation Laws. Range_ Heater_D.W. APPLICANT
Oven _ Dryer_W.M._ `ADDRESS �L
Date Applican Top _ FAU _W.H..
Hood _ Fan _Other_ CITY Tel No.
NOTI E TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond.— LICENSE OR
Exemption, you should become subject to the Workers' EG.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
Up to 1 Incl �j
FINAL ,
LICENSED CONTRACTORS DECLARATION
Over 1 to 10 Incl. DATE VALIDATION
Over 10 to 50 Incl. i
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
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 V
License Num Lie.Class 0-200 Amp. Under 600 V �v
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECL RATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt, from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code): 0 5 7.4 A
Misc.Conduits&Conductors
, as owner of property, will e work anthe
❑ If thtill dthk d
Other (See Complete Fee Schedule)— 4 o`0 0 0 0 2
structure is. not intended or offered for sale (Section
7044, Business and Professions Code). 2 ° o31,80
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 3
for the performance of the work for which this permit is ° ° ° 3 1,8 0 U
PERFEE (Sub-Total)
issued(Sec. 3097;civ.C.). 0 7 30-18 1
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE 0
1 certify that I have read this application and state that the TOTAL FEE 3 d
Vh
inn is correct.I agree to comply with all County
State laws regulating Electrical wiring, and
�pr tatives of this County to enter upon
erty for inspection pur oses. SEE'REVERSE FOR EXPLANATORY LANGUAGE
�I
Signature o Permittee Date