HomeMy Public PortalAbout9994 BOGUE ST_Electrical__ .WORKERS' COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I herebyCE-806 affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800, Lab C )
t •
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
S — g�fsEE ��
Certified copy is filed with the county buildingm1 & 2-Family,Y. q Ft. $ $ LOCALITY,
hAREST
on department MultiNE
family Sq. Ft. CROSS ST
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets- Rec�Light�Sw MAIL
COMPENSATION INSURANCE ADDRESS
First 20
(This section need not be completed if the work involved by Total No. Additional- CITY Tel. No
the permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this PPLICANT
permit is issued, I shall not employ any person in any manner
so as to b come subject to the Workers'Compe anon Laws. Lighting Fixtures First 20 ADDRESS
Total No— Additional
�r CITY Tel. No.
Date O Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO PPLICANT. If, after making this Certificate APPLICANT
Exemption, you should become subject to the Work Range_ Heater_D.W. —
Compensation 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 revoked Hood _ Fan _ Other— CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Disp. Room Air Cond LICENSE OR Class.
I hereby affirm that I am licensed'under provisions of Chapter 9 REG NUMBER >„
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROLE E BY
and Professions Code,and my license is in,full force and effect Power Apparatus 8 Large Appliances ^ y
Size &Type HP, KW, KVA, or KVAR /✓1 `.0 iV{
License Number Lic. Class U to 1 Incl 1�� O
Up FINAL �
Over 1 to 10 Incl DATE
Contractor Date VALI TION
Over 10 to 50 Incl. FINAL a
I am exempt under Sec Over 50 to 100 Inc. BY <n
B&P C for this reason Over 100_ 41 4 0 A
Z
Date: Services, Swbd , MCC & Ponelboards ,
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V #,0 0 0 0 0 2
Over 1000 Amp. or Over 600 V o o rj 0
Exemption for Reg. Maint Elect.
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit o 0 o 1 35050
1 hereby affirm that I am exempt from the Contracto'r's License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5, Business and
Prof cions Code)- 02'2 8 I$6
I, as owner of the property, will do the work and the Misc Conduits &Conductors
structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule)_
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 issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ C )
A PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 3tJt/
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and i
hereby authorize representatives of this County to enter upon
the bove-mention roperty for inspection-purposes SEE'REVERSE FOR EXPLANATORY LANGUAGE
/� Signature of Permittee Ir IF Datf-