HomeMy Public PortalAbout9995 BOGUE ST_Electrical__ t yWORrCO/V1PENSATION DECLARATION 76A663 10/81 ,
rl�iAereby arfirn that I have a certificate of consent to self CE-806G APPLICATION FOR ELECTRICAL PERMIT
n#um, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES `BUILDING AND SAFETY
or a certified copy thereof (Sec 3800, Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB /
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS �/&f74(9_
❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq Ft $ — $ LOCALITY
tion department. Multi-family Sq Ft — NEAREST
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Residential Swimming Pools CROSS ST
OWNER OR
Date Applicant '�f FIRM NAME 00<1
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CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�e/tight_ �$w. C MAIL
COMPENSATION INSURANCE AD20 DRESS Y
This section need not be completed if the work involved b �j First ti
( p y Total No. r25J Additional p CIT �� Tel. No. 6
the permit is for one hundred dollars($100)or less.) -
I certify that in the performance of the work for which this PLAN CHECK
APPLICANT
'permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws Lighting Fixtures First 20DDRESS
Additional Z
Total No CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' Range Heater—D.W. APPLICANT
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer _ W M. Jt— ADDRESS
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. CITY Tel. No.
Hood Fan _ Other_
LICENSED CONTRACTORS DECLARATION (' LICENSE OR
1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG NUMBER Clbss/'� }
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED,,BY Power Apparatus& Large Appliances
and Professions Code, and my license is in full force and effect. � /� r U
Size &Type HP, KW, KVA, or KVAR r [l
License Number Lic Class Up to 1 Incl. FINAL
Over 1 to 10 Incl DATE
Contractor Date
VALI TION
❑ Over 10 to 50 Incl. FIN W
1 am exempt under SecOver 50 to 100 Inc. BY d
Z
B BP.0 for this reason Over 100 Z
Date: Services, Swbd., MCC & Panelboards'
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V 2 9,6'8 A.
❑ Exemption for Reg. Maint. Eject Over 1000 Amp. or Over 600 V
# o o'0 0 0 2
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I o o 6 a 2 5
1 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 o 0 - 6a255
Professions Code)
❑ 1, as owner of the property, will do the work and the Misc Conduits&Conductors 0 9,20-85
structureis 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 )
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
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the;;r en ed property for inspection purposes •
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date