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WjEwERS' COMPENSATION DECLARATION to/Bl
CE-806G APPLICATION FOR ELECTRICAL PERMIT
j'.I hed6by affirm that I have a certificate of consent to self CE-806
insuro, orla 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. Residential Bldgs. & Pools EACH NO. FEE ADDRESS 771i
New Renti
eS ,¢(ie,
❑ —
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. g $ LOCALITY �/�h��
tion department. Multi-family Sq. Ft. — NEAREST
�✓�l ,d/rARi (/{�
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR
_ FIRM NAME (y�J� G T ICIJt
CERTIFICATE OF EXEMPTION FROM WORKERS' � AIL
Outlets: Rec Light Sw.
COMPENSATION INSURANCE ADDRESS V L�Xi 4G S /�
First 20 �'��I,� S`•
(This section need not be completed if the work involved by Total No.. Additional 1-7F E
CITY r�,t�® ��� Tel. No 3
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this PLAN CHECK
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
pp Total No. Additional
Date 4 OL Applicant CITY Tel. No.
NOTICE O PLICANT: If, after makin this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range_ Heater—D.W. _ APPLICANT W!!G!e—
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 No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
Dis _ Room Air Cond. —
I hereby affirm that I am licensed under provisions of Chapter 9 p' REG. NUMBS lass. }
(commencing with Section 7000) of Division 3 of the Business power Apparatus 8 Large Appliances DISTRICT O. P CESS D BY 0
and Professions Code,and my license is in full force and effect. Q Q
Size &Type HP, KW, KVA, or KVAR (� V
License Number Lic. Class Up to 1 Incl. F ��
Over 1 to 10 Incl. "1'
Contractor Date � ALIDAT
❑ Over 10 to 50 Incl. F W
I am exempt under Sec. Over 50 to 100 Inc. B N
B.&P.C. for this reason Over 100 /r Z
Date: Services, Swbd., MCC & Ponelboards 'O(, / �lylPoo. /
0 -200 Amp. Under 600 V Zl�
4 X—Signature 201 - 1000 Amp. Under 600 V `
D 1
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole & Appurtenances ;2 5 2 a 9 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License #,o o o o 0 2
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits I
Professions Code): )'0 0 26-00
I, as owner of the property, will do the work and the Misc. Conduits &Conductors '0.0 0 2 0.0 v
structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule)_ ,
.7044, Business and Professions Code). 0 a 2:1 -8 6
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 od
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
thea ove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Of Permittee Date