HomeMy Public PortalAbout5025ALESSANDRO AVE_Electrical (2) WnsWORKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
by affirm that I have a certificate of consent to self CE-806G
or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
ertified�gp�hereof (Sec. 3800, Lab. C.) ��o. 6�1//��///�/ Company FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. EACH NO. FEE ADDRESS
PY. y New Residential Bldgs. & Pools
® 1 & 2-Famil S Ft. $ — $ LOCALITY
Certified copy is filed with the county building inspec- Y- 9
tion department. Multi-family Sq. Ft. NEAREST
3- - -Applicant �.� Residential Swimming Pools CROSS ST.
Date A e'^
OWNER OR.
FIRM NAME ti -
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No. CITY Tel. No.
the permit is for one hundred dollars ($100)or less.) Additional x`171 C' �67d
PLAN CHECK
I certify that in the performance of the work for which this APPLICANT AJ C_J-
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 5
i
Total No. Additional
Date Applicant CITY
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT v1
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. CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
LICENSE OR Class.
Disp. Room Air Cond. h
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER,�
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. PROCESSED
and Professions Code, and my license is in full force and effect.
A Size & Type HP, KW, KVA, or KVAR'
/ � �/CLic. Class l�
License Number 2 Up to 1 Incl. FINAL
�/ _15P,
_ Over 1 to 10 Incl. DATE r VALIDATION 0
Contracto�J �n /�/ Date C'� Over 10 to 50 Incl. 4FINAL w �
❑ I am exempt under Sec. Over 50 to 100 Inc. BY P r u U
B.&P.C. for this reason Over 100 `el
Date: Servi boards l— ►
0�20Omp. Under 600 V
Signature 201mp. n er 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. r 4 2 A
SINGLE FAMILY Temp. Power Pole&Appurtenances o c o2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License o 2 r 0
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): � 0 2 r �0
IDI, as owner of the property, will do the work and the Misc. Conduits& Conductors r
Fee Schedule Complete(See S
structure is not intended or offered for sale (Section Other ( P )— ,
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 -7 �
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
the above-menti ned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date o