HomeMy Public PortalAbout6029ALESSANDRO AVE_Electrical WORKERS'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 ANGELES 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 SOB
Policy No. CompanyEACH NO. FEE ADDRESS Gat 1 �� p7 y
New Residential Bldgs.&Pools
0 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY 4
Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST WCe>f J I
department. Residential Swimming Pools FIRM NAME
UA N C s
Date Applicant Outlets: Rec.—Light Sw. MAIL
First 20 ADDRESS /" / e,-14 C'
CERTIFICATE OF EXEMPTION FROM WORKERS',- Total No. Additional CITY �Ly�,r. Tel No. �-_�Z d
COMPENSATION INSURANCE PLAN CHECK O
(This section need not be completed if the work involved APPLICANT U
Additional
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First ADDRESS X
Additional
Total No. O
I certify that in the performance of the work for which this CITY Tel No. U
permit is issued, I shall not em Fixed Appliances Not Over 1 HP
employ any person in any manner PERMIT
so as to become subject to th Workers' Co Zpensan L S. Range_ Heater D.W. APPLICANTk /<' /- -a S� n c- Off.
Oven Dryer_W.M. ADDRESS // to
pate 'Z'� ��An1ican Top FAU _W.H. ` ��H (1 /D
/ Hood Fan _Other_ CITY 1 Tel No.4/41
NOTICE TO APPLICANTOf
after making this Certificate of Disp. Room Air Cond._ LICENSE OR vc�� / ra `� 6
Exemption, your shouldcome subject to the Workers' REG.NUMBERoG.I O f��yClass C
Compensation provisionsthe Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR
deemed revoked.
Up to 1 Incl. "
Over 1 to 10 Incl. FINAL
DATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. 9 VALIDATION
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
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
<< 4.306A
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit 0Jo 0 0,0 2
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
2'.-'-
ness and Professions Code): 2+ I �•J,,J
Misc.Conduits&Conductors 0 0 2 5 0 2
0 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section O 9, 2 0_U
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 PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.).
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
above information is correct. I agree to comply with all County
ordinances and State laws reguirting Electrical .wiring, and
hei,eb authorizd 4prort�y�:erepresentative f this County to enter upon
the ve-mentioneinspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date