HomeMy Public PortalAbout4833 ENCINITA AVE_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 to/at 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
ElCertified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS C /y
❑ yy�
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
CROSS ST.
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME 2i (Ji
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight Sw.— MAIL
q
COMPENSATION INSURANCE ADDRESS 6� /Y/
(This t bcompleted if the work involved b First 20
( s section neenoe com p Y Total No. Additional CITY � C -'• Tel. No.'Zk5_b 3
the permit is for one hundred dollars ($100)or less.)
I certifythat in the performance of the work for which this PLAN CHECK
P APPLICANT
permit is issued, I shall not employ any er on in kannerso as to become subject to the Work gso
sLighting Fixtures First 20 ADDRESS
Total No. AdditionalCITY Tei. No.
Date — Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making tertificate 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. Hood Fan Other CITY
_ L� 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 j S/ CIassC/e
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PRO CE ED BY
and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances — y
_ / /j Size &Type HP, KW, KVA, or KVAR' �0
License Numb 1:1o Lic. Classes Up to 1 Incl. FINAL
L Over 1 to 10 Incl. DATE --u/ 7 f�4 VALIDATION
Contractor Date Over 10 to 50 Incl.
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY
Over 100
B.&P.C. for this reason
Date:
Services, Swbd., MCC & Ponelboards ,
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V 9.1 8 76 A
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. 0 0 0 0 0 2
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ,2 -,o25-50
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits 0 0 0 2 ja Q
Law for the following reason (Section 7031.5, Business and 2.
65
5,
Code): 0 6 1
❑ 1, 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.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE V
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
ordinanc a d y
ating Electrical wiring, and
of this County toenter upon
r inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa ure o Permittee Date