HomeMy Public PortalAbout10684 ARROWOOD ST_Electrical_7/21/1980_light outlets and switch WORKERS'COMPENSATIONDECLARATION
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 J
Policy No. Company t7 QG(
New Residential Bldgs.& Pools EACH NO. FEE
New
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — Is I LOCALITY ,e e
Multi-family Sq. Ft. — NEAREST
M Certified copy is filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER OR -�1-
FIRM NAME j/}#1e OlPtW
Date Applicant Outlets: Rec.:Light S., /f- MAIL '
First 20 u ADDRESS ®V'_
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No.
COMPENSATION INSURANCE. PLAN CHECK C
(This section need not be completed if the work involved �6a �, APPLICANT _ O
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS
Additional cc
Total No.� O
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. 1-
permit is issued, I shall not employ any person in any manner PERMIT
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT 07 WLU
CL
Oven Dryer W.M. ADDRESS to
Z
Date Applicant Top FAU _W.H.
Hood Fan —Other
CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond.— KENS
Exemption, you should become subject to the Workers' REG M B E R Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. P ED BY
with comply with such provisions or this permit shall be � A 1
deemed revoked. Size&Type HP, KW, KVA,or KVAR ( t C✓ C% 0` /
Up to 1 Incl.
FINAL
Over 1 to 10 Incl-. DATE
LICENSED CONTRACTORS DECLARATION VALIDATION
Over 10 to 50lncl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
BY
9 (commencing with.Section 7060)of Division 3 of the Busi- Over 100
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 a Sign with One Branch Circuit
License Law for the following reason (Section 7.031.5, Busi- Additional Sign, Branch Circuits
ness and Professions Code):
Misc.Conduits&Conductors
I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
tructure is not intended or offered for sale (Section
7044, Business and Professions Code). o
CONSTRUCTION LENDING AGENCY z 311,4 A
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is #'o 0.-0.0 o 2
issued (Sec. 3097,Civ.C.). PERMIT FEE (Sub-Total)
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 2 0 0 2 Q
Lender's Address PERMIT ISSUING FEE Oa 0 2 Q 010 20
I certify that I have read this application and state that the TOTAL FEE 72 1 '
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 Permittee Date