HomeMy Public PortalAbout5721ALESSANDRO AVE_Electrical WORKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or 7r--(f
a certified copy thereof(Sec. 3800,Lab. C.)
FOR APPLICANT TO FILL IN SOB
Policy No. Company — EACH NO. FEE ADDRESS S iP��S NQ
New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY _ �S
Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST S
Residential Swimming Pools
department. WNER OR
FO RM NAME /
Date Applicant Outlets: Rec.—Light Sw. MAIL
First 20 ADDRESS �ESSA.1/17��
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY';Wjj /
t✓ 7 r Tel No. � Z }
COMPENSATION INSURANCE PLAN CHECK d
APPLICANT 0
(This section need not be completed if the work involved
LightingFixtures
by the permit is for one hundred dollars ($100) or less.) First 20 ADDRESS V
Additional
Total No.
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. 0
permit is issued, I shall not employ any person in any manner PERMIT 0
so as to become subject to the.Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT AjrW
a.
Oven Dryer_W.M. ADDRESS
XDate r/%7—F( Applicant lag
Top FAU _W.H. _
Hood Fan —Other— CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond-_ LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROC SSED BY
with comply with such provisions or this permit shall be Size&Type HP, KW, KVA,or KVAR
deemed revoked. Q
Up to 1 Incl.
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE VALIDATION
y �
Over 10 to 50 Incl. / ®
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 8Y
ness and Professions.Code, and my license is in full force and
effect. Services
License Number Lic.Class 0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp,or Over 600 V
HOME OWNER-BUILDER DECLARATION 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): z 1 7 8 5 A
Misc.Conduits&Conductors
���
1, as owner of the property, will do the work and the # b 0 0;0 0 2 Other (See Complete Fee Schedulel—
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 2 0.b 1 9.50
CONSTRUCTION LENDING AGENCY
11 hereby affirm that there is a construction lending agency -'o o 1 9,50 Fl
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.). 1.0 2-81
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE / C Sa '
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-mentioned property for inspection purposes: SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of e—rmil!,eAIFI Date