HomeMy Public PortalAbout10140 BOGUE ST_Electrical__ WORKERS' COMPENSATION DECLARATION 10,8,
CE-806G APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm-that I have a certificate of consent to self CE-806
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
i or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No:,_ { Company' `'' FOR APPLICANT TO FILL IN JOB 01
Certified copy is hereby furnished. New Residential Bldgs.A Pools EACH NO FEE ADDRESS
' 1 & 2-Family, S Ft $ — $ LOCALITY
'Certified copy is filed with the county building mspec- Y• 9 ' — °
e tion department ' Multi-familyS Ft NEAREST
J /�r r Residential Swimming Pools CROSS ST
Date 1 Applicant OWNER OR
7FIRM NAME
(. CERTIFICATE OF EXEMPTION FROM WORKERS'!) Outlets: Rec Light Sw MAIL r'
COMPENSATION INSURANCEADDRESS
First 20
F(This section need not be completed�if the work involved by Total No. - ( Additional ,:.._ CITY -f,• , Tel ,No
the permit is for one hundred dollar ($100)or less.) '
PLAN CHECK
I certify that in the performance ofJrthe work for which this , APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation, Lighting Fixtures First 20 "`= t ADDRESS
� •„�, I }i p t rr Additional •.�'. � � -
r Total No. ` + ! CITY Tel No:
Date'{ +? Applicant f, ''-
” Fixed Appli nces Not Over 1 HP PERMIT
NOTICE TO APPLICANT If, after`making thi3 Certificate of APPLICANT.'
Exemption, you should become subject, to the Workers' Range_ Heater_D W. —
Compensatioh 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 CITY revoked Tel. No' `
Hood Fan _ Other— '
LICENSED CONTRACTORS DECLARATIONLICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class r
(commencing with Section 700.0) of Division 3 of the Business DISTRICT NO PROCES ED BY- d
Power Apparatus 8 Large Appliances ; ..— O
and Professions Code,and my license s m full force and effect. \ t, �;• r
>,
Size A Type HP, KW, KVA, or'KVAR' % ,}„r',, U
License Number r Lic Class Up to 1 Incl. FINAL ! �� LU
S r Over 1 to 10 Incl. DATE ,i VALIDATION 4-
Contractor Date v` r
❑ Over 10 to 50 Incl.. FINAL �•
I am exempt under Sec Over 50 to 100 Inc. BY
B'&P C. for th'i's reason Over 100 0
Services, Swbd , CC & Panelboards ` d
M
Date 0 - 200 Amp. Under 600 V ► '. W
Signature'-- 201 -1000 Amp. Under 600 V .+
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg Maint Eject
SINGLE FAMILY Temp Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with,One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code). 1
1, as owner of the property, will do the work and the Misc Conduits 8 Conductors - ;a,„ i�• '_;
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044, Business and Professions Code) +k•,t. .
CONSTRUCTION LENDING AGENCY i +t-I I` 47 P
I hereby affirm that there is a construction lending agency for tFs•1 �'• �j' M ,�
the performance of the work for which this permit is issuedPERMIT FEE (Sub-Total) "
(Sec 3097, Civ C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Len_'der's Address � .F '•^�' "="
I certify that I have read this application and state that the . TOTAL FEE ' r"• ,fir,"°
above information is correct I agree to comply with all County
ordinances and,State laws regulating Electrical wiring, and, '
hefeby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes
r a: SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature-of Permittee ; Date