HomeMy Public PortalAbout10516 FREER ST_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERAIT
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 ) D
Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS �(D
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
Certified copy is filed with the county building inspec- 1 &2-Family, Sol Ft $ — $ LOCALITY
tion department Multi-family Sci Ft —'NEAREST
Residential Swimming Pools CROSS ST yy���9 -I
Date Applicant WNER OR
FFIIRM NAME /'I�✓• ��� COR/1�C rLL+
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 CIT ��/�P�C�� Tel. No. 171-2
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 Workers'Compensation Laws'. Lighting Fixtures - First 20 ADDRESS
-/ �1� n Total No Additional
,4D' e� ! Applicant.4Wr CORA1E� CITY. Tel No.
Fixed Appliances Not Over 1 HP PERMIT
NOTIC TO A PLICANT 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. NUMB R/ ass.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
y
and Professions Code, and m license is in full force and effect. Power Apparatus& Large Appliances r >-
Size &Type HP, KW, KVA, or KVAR i 0
License Number Lic. Class V
at
Up to 1 Incl. FINAL
Contractor Date Over 1 to 10 Inc[. DATE �.- � �� •VALIDATION O
Over 10 to.50 Incl. FINAL �5��°° TTT---
I am exempt under Sec Over 50 to 100 Inc. BY
IL
B.&P.0 for this reason Over 100
Date- Services, Swbd , MCC& Ponelboards ►
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. 218 9 1.4 A
SINGLE FAMILY Temp. Power.Pole &Appurtenances .#,o:o --'2
2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License 12.-;-,2 5 5 0
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code). 0 0'02550.x
Misc. Conduits & Conductors '
I, as owner of the property, will do the work and the POO 2,.1 4-8 4
structure is not intended or offered for sale (Section Other (See Complete Fee Sched'ule)_
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
Lender's Address
I certify that I have read this application and state that the TOTAL FEES
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 Permittee Date