HomeMy Public PortalAbout5037ALESSANDRO AVE_Electrical WORKERS COMPENSATION DECLARATION CE 806 10/81 APPLICATION FOR ELECTRICAL PERMIT J�
CE 806G
Ithc,�.�9t;affirm that I have!a certificate of consent to self insure
or arccrc�ficate pf� li;er�r Cbmpensatlon Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 06'Lab C)
Policy NO Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnishedEACH NO FEE ADDRES
New Residential Bldgs &Pools
❑ Certified copy is filed with the county building inspection 1 & 2 Family Sq Ft $ — $ LOCALITY
department 'Q Multi family Sq Ft — NEAREST
CROSS ST
Date Applicant
"' Residential Swimming Pools i OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS � 5 FMAIL
IRM NAME
COMPENSATION INSURANCE Outlets Rec LighfF,
Sw ADDRESS
(This section need not be completed If the work involved by the rst 20
permit is for one hundred dollars($100)or less)
Total No Additional CITY Tel No
I certify that in the performance of the work for which this permit PLAN CHECK
is issued I shall not employ an v APPLICANT
p y y person in any manner so as to
become subject to the Worker's Compen anon Laws Lighting Fixtures First 20 ADDRESS
Total No Additional
/f CITY Tel No
Date�V ����* Applican �
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
„"Exemption you should become subject to the Workers Compensation Range_ Heater_ DW _ APPLICANT
provisions of the Labor Code you must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS
provisions or this permit shall be deemed revoked Top - FAU WH _
LICENSED CONTRACTORS DECLARATION
Hood Fan T- Other- CITY Tel No
I hereby affirm that I am licensed under provisions of Chapter 9LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and Disp - Room Air Cond REG NUMBER Class
Professions Code and my license is in full force and effect Power Apparatus& Large Appliances DISTRICT NO or PROCESSED
Size& Type HP KW KVA or KVAR c �U( 0
License Number Lic ClassU
Up to 1 Incl FINAL,
Contractor Date Over 1 to 10 Incl DATE --� rC/� V IDATION 0
❑ Over 10 to 50 Incl FINA
I am exempt under Sec Over 50 to 100 Inc BY W
B&P C for this reason Over 100 ;2 8 1 6 7 A �
Sery
Ves Swbd MCC& Panelboards Z
Date 0 200 Amp Under 600 V # o o s s o 2
Signature 201 1000 Amp Under 600 V I'° 3 9 5 0
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect oro - 39505
SINGLE FAMILY _ Temp Power Pole& Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit 1 22-87
1 hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuits
for the following reason (Section 7031 5 Business and Professions
Code)
I as owner of the property will do the work and the structure Misc Conduits & Conductors
s not intended or offered for sale (Section 7044 Busmess Other(See Complete Fee Schedule) ,
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(Sec 3097 PERMIT FEE (Sub Total)
Civ C)
PLAN CHECKING FEE
Lenders Name
PERMIT ISSUING FEE
Lenders Address
I certify that I have read this application and state that the above TOTAL FEE t S
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 mentioned
pr pert for mspectio u Qses, SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permdtee Date i