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Home My Public Portal About8833 ELM AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 loiet APPLICATION FOR ELECTRICAL PERMIT I hereby 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.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. Ft. — NEAREST CROSS ST. Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 'ADDRESS (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.) that in the performance of the work for which this PLAN CHECK I certify P 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 20 ADDRESS Total No. Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT Exemption, you should become subject to the Workers' 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. CITY Tel. No. LICENSED CONTRACTORS DECLARATION Hood Fan _Other_ Disp. — Room Air Cond. LICENSE OR Class. i 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 NOPROCESSED BY d and Professions Code, and my license is in full force and effect. Power Apparatus & Large Appliances O Size & Type HP, KW, KVA, or KVAR U License Number Lic. Class Up to 1 Incl. FINAL LU Over 1 to 10 Incl. DATE VALIDATION Contractor Date❑ Over 10 to 50 Incl > FINAL Ix I am exempt under Sec. Over 50 to 100 Inc. BY <Q B.&P.C. for this reason Over 100 O Services, Swbd., MCC & Panelboards Date: 0 311111. d -200 Amp. Under 600 VLU Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V 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): f ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors Y structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , « '6 • 7044, Business and Professions Code). , r CONSTRUCTION LENDING AGENCY a 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 laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE-806G 10/81 APPUCATION FOR Rscumc*kL nmu I hereby"affirm that I have a certificate of consent to self CE- G' � insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lob. C.) Policy No. Company i FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ❑ LOCALITY U �' ITY Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ - NEAREST tion'departmeni. Multi-family Sq. Ft CROSS ST.' Residential Swimming Pools OWNER OR . Date Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' • � MAIL COMPENSATION INSURANCE Outlets: Rec Light Sw. `ADDRESS This section need not be com leted if the,work involved b First 20 ( p Y Total No. Additional CITY TeL.No. the permit is for.one hundred dollars ($100)or less.)' — Additional I certifythat in th 'performance of the work'for which this PLAN CHECK eP APPLICANT � permit is issued, I shall not*employ any person in any manner J so cis to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS Total No.- Additional CITY Tel. No. , Date •� U- 3 Applicant /1rL>LA�'�ZL/)L /� Fized Appliances Not Over 1 HP PERMIT ti 'NOTICE TO APPLICANT: If, aftermaking'this Certificate of APPLICANT z' (�L Exemption, you should become subject to the Workers' Range_ Heater—D.W. — Compensation provisions of the Labor Code; you must forth- Oven _ Dryer — W.M.— ADDRESS S• with comply with such provisions or this.permit shall, be Top ' — FAU —W.H. — deemed revoked. Hood Fan _ Other_ CITY r ^-- Tel.-No. _ LICENSED CONTRACTORS DECLARATION 'LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class.' (commencing with Section 7.000) of Division 3 of the Business DISTRICT NO. PRO ED BY and Professions Code, and my`license is in full force and effect. . Power Apparatus.& Large Appliances } Size &Type HP, KW, KVA, or KVAR' 1 L./ License Number • Lic. Class C_— /9Up Incl. FINAL V -� Overr I to 10 Incl. DATE 19kl�WX Controctor ' �G/��%♦✓9ate 'e 5 o VALIDATION Over 10 to 50 Incl., FINAL ❑. 1 am exempt under Sec. Over 50 to 100 Inc. BY ( . d B.&P.C. for this reason' Over 100 N Services, Swbd), MCC & Panelboards Z_ Date: Services, -200 Amp. Under 600 V D Signature 201 -'1000 Amp. Und6r'600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg.,Maint-. Elect. 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): 2 P ❑ I, as owner of theproperty, will do the work and the Misc. Conduits& Conductors {: o o.o o•a 2 structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)- 7044, Business and Professions Code). D 1 0'o 2 0,2 r CONSTRUCTION LENDING AGENCY c o o t(}C U 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) t 0 5-8 3 (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 laws regulating Electrical wiring, and. hereby authorize representatives of.this County to enter upon the above ntioned property f nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 14 S' nature of Permittee Date