HomeMy Public PortalAbout10640 DAINES DR_Electrical__ • ., W09KERS'COMPENSATION DECLARATION EAB63 tN/et
CE-806G APPLICATION FOR ELECTRICAL PERMIT. {�
1 hereby affirm that l.havd a certificate of consent to self insure, �J
or a certificate Df Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES • BUILDING AND SAFETY
copy thereof(Sec.3800.1-ab. C.)
• Policy No. - Company, FOR APPLICANT TO FILL IN - JOB `�'�f' ^,� '+ f
❑ , Certified copy is herebyfurnished. EACH.. NO. ,. FEE ADDRESS IoM-o ,� A n/
,New Residential Bldgs.& Pools
❑ 1 & 2-Family,Sq.Ft.
rtifi $ - — $ LOCALITY
Ceed cagy is.filed with the county, building inspection
department. Multi-family Sq.Ft. NEAREST
.NEARS ST.'
Date Applicant r- Residential Swimming Pools OWNER OR
- q' < .FIRM NAME -
• CERTIFICATE OF EXEMPTION FROM WORKERS' ' ' � 1 MAIL -cc I ,I
• - COMPENSATION INSURANCE Outlets:Rec Light — Sw, , r, : /C ADDRESS• A'f3l:y l
(This.section need not be completed if the work involved by the
First 20 Q !V
permit is for one hundred dollars'($100) or less.). Total No. Additional D CITY G' Tet.No.
I certif •that in the erformance of the,work for.which this permit - PLAN O K " - '
Y, P P PPUCANT
is issued I shall not employ any person in any manner so as to -become subject to the Workers'Compensation Laws. Lighting Fixtures First 20- J ADDRESS -
1 Additional
Total No. - CITY Tel; No.
Date Applicam Fixed.Appliances Not Over-1 HIP -
ERMIT
NOTICE O APPLICANT: If, after making this erJficat of APPLICANT
Exemption,you should become subject to the Workers'Corf pensalion Range_ Heater_ D.W. `
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS p _
provisions or this permit shall be'deemed revoked. _Top — FAU W.H. _ Ci �-
LICENSED CONTRACTORS DECLARATION Hood Fan Other_ `l
CITY �r,PLC- Tel.No. &V 0
I hereby affirm that l am lice6sed under provisions of Chapter 9 LICENSE OR -
(comTencing with Section 7000) of Division 3 of the Business and Use. — Room Air Cond. REG.NUMBER Class.
Professions Code,and my license is in full force and effect. DISTRICT NO PROCESSED BY
Power Apparatus& Large Appliances �Q
Size & Type HP,KW,KVA,or KVAR _ 0
License Number Lia Class 'Up to 1 met.' - FINAL r V
Over 1 to 10 mc1. DATE • ,� no
VALIDATION
Contractor - Date - O
❑ Over 10 to 50 Incl. � FINAL . F"
1 am exempt under Sec. Over 50 to 100 Inc _ BY // W
BARG'. for this reason Over 100
Services, Swart.,MCC& Panelboards
Date: 0-200 Amp.Under 600 v
,Signature 201 - 1000 Amp,Under 600 V -
Over 1000 Amp.or Over 600 V # e e 1• e e '2
Exemption for Reg.Maint Elect-
' SINGLE FAMILY- Temp.Power Pole& Appurtenances _ ' �� e e 3 a 2 5
HOME OWNER-BUILDER DECLARATION Sign with One Branctr Circuit
1 hereby affirm that I am exempt from the Contractor's License Law • a'e e 3 a 2 5 U
for the following reason (Section 7031 5,Business and Professions` Additional Sign Branch Circuits -
Code): 1 0526 '..88
I,as owner of.the property,will do the work and the structure Misc.Conduits &Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
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(Sec.3097, PERMIT FEE (Ruh Total)... ;Z-7Z-
Civ.
C.1.
Lender's Name
PLAN CHECKING FEE
. - - �- .•
PERMIT ISSUING FEE. _
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE 8'
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 p rposes. - -
SEE REVERSE FOR EXPLANATORY.,LANGUAGE
Signaldre,of Permittee V Date ( -