HomeMy Public PortalAbout4930 ENCINITA AVE_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, or a certificate�f.Wbrke`rs' 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 co s hereb furnished. EACH NO. FEE ADDRESS
PY Y New Residential Bldgs. & Pools
❑ Certified copy is filed with the county building inspec- y, q. — LOCALITY -�
1 & 2-Family, 5 Ft. $ — $
tion department. Multi-family Sq. Ft. CROSSNEAREST.
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME Af
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS /Z / L_ I>
(This section need not be completed if the work involved by Fist 20
the permit is for one hundred dollars ($100)or less.) Total No. Additional CITY Tel. No� ��
I certify that in the performance of the work for which this PLAN CHE
Cf
APPLICANT
permit'is issued, I shall not employ any person in any manner
so as to become subject to the Wo rs'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY No.
Dat AppIican �� 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. Hood _ Fan _Other_ CITY 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 7000) of Division 3 of the Business DISTRICT NO. PROCESS B a
and Professions Code,and my license is in full force and effect. Power Apparatus & Large Appliances
Size &Type HP, KW, KVA, or KVAIR
License Number Lic. Class Up to 1 Incl. FINAL d:
Over 1 to 10 Inc[. DATE �/ r� VALI TION �
Contractor Date Over 10 to 50 Incl. FINAL G 1,
❑ I am exempt under Sec. Over 50 to 100 Inc. BY N
Over 100
8.&P.C. for this reason
Z
Date: Services, Swbd., MCC 8 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 &Appurtenances
HOME OWNER-BUILDER DECLARATION Sign _w,7ne Branch Z,rcuit
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):
❑ I, 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 -0 4 8 Q 9 A
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) f
(Sec. 3097, Civ. C.).' PLAN
PLAN CHECKING FEE # o o,o.o o 2
Lender's Name
PERMIT ISSUING FEE ° o25.50
Lender's Address o o,o 2 S 5 0 C5
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 Q �`� 2`�$6
hereby authorize representatives of this County to enter upon
Atbove-mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date