HomeMy Public PortalAbout6006 CLOVERLY AVE_Electrical__ ' WORKER' CQMf'ENSATION DECLARATION 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT
h&eby-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
or a certified copy thereof (Sec. 3800, Lab. C.)
e
Policy No. Company FOR APPLICANT TO FILL IN JOB ���'d� t
❑ Certified co is hereby furnished. EACH NO. FEE ADDRESS ((J (�J C/
PY Y New Residential Bldgs. & Pools
❑ 1 & 2-Family, S Ft. 2 $ _ $ LOCALITY T Y11
Certified copy is filed with the county building inspec- Y- q
tion department. Multi-family Sq. Ft. NEAREST ��� Gvim
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR K + (1 ^ I^ 1�
^� FIRM NAME K . J`ti /` !��10 L4
CERTIFICATE OF EXEMPTION FROM WORKERS' .Outlets: Rec LightZ2�sw.•! MAIL Q
COMPENSATION INSURANCE ADDRESS u b{1/l to let Yl Y,
This section need not be completed if the work involved b \ 0� First 20
( p Y Total No.�(,c Additional CITY � �jQ�- Tel. No.2S/f6J�/3
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Worker ompensation Laws. Lighting Fixtures First 20 ADDRESS
Total NO. b _ Additional `
//''�� 1`1 CITY Tel. No.
Date pplicant 1 Fixed App ces Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of • ! It — AppLICANT"'I
Exemption, you should become subject to the Workers' Range' Heater,D.W
Compensation provisions of the Labor Code, you must forth- Oven 7,T L.Dryer -W.M.-- ADDRESS
with comply with such provisions or this permit shall be ~~ Top" -FAU ,,`W.H:
deemed revoked. CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood rT Fan ` _ Other_
Disp. 3L Room Air Cond. LICENSE -.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. / PROCESSE Y a
and Professions Code, and my license is in full force and effect. Power Apparatus 8 Large Appliances �, GfCaJ( O
3�1 � Size 8 Type HP, KW, KVA, or KVAR' V c 0
License Number Lic. Class Up Up to 1 Incl. FINAL of
Over 1 to 10 Incl. DATE f �i � r O
Contractor Date e Gi c/ So VALI TION
❑ Over 10 to 50 Incl. FIN
W'
1 am exempt under Sec. Over 50 to 100 Inc.
B.BP.C. for this reason Over 100 / Z
Z
Date: Services, Swbd., MCC & Panelboards
0 -200 Amp. Under 600 V <
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole 8 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 g
Professions Code): oto+o o'o
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors # 2
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
a 9.6,1 0
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY o,o;o 9 6,1 Q'v
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) 0 611 8,v 8 6
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address 116 ,16 I certify that I have read this application and state that the TOTAL FEE a
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby horize repWop
his County to enter upon
I he:byTme rrr����onespection purposes.n u SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date �j