HomeMy Public PortalAbout8732 GARIBALDI AVE_Electrical__ WORKER S'COMPENSATIOND> LARAT;ON CE-806G (2-80)CE� APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have ■ certificate of comept to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
Insure,
or ■ certiflcste of Workers'Compensation Insurance,or
■certified copy thereof(Sec:3800,Lab.C.)
FOR APPLICANT TO FILL IN ,JQB
Policy No. Company EACH NO. FEE ADDRE3S
New Residential Bldgs.&Pools
sM
F-1 Certified copy Is hereby furnished. 1 &2-Family,Sq. Ft. — = LOCALITY
NEAREST
❑ Certified co is filed with the coup building Multi-family Sq. Ft.
department.Py g Lnspectio❑ Residential Swimming Pools CROSS 3T
OWNER OR
FIRM NAME a
Date__ Applicant Outlets: Rec."-__Light Sw. MAIL
"first 20 A D
CERTIFICA'T'E OF EXEMPTION FROM WORKERS' Total No. Additional /
COMPENSATION INSURANCE PLAN CHECKCIT� V e I Tel No.QC Q /
(This section need not be completed if the work involved APPLICANT O
by the permit is for one hundred dollar (;100) or less.) Lighting Fixtures First 20
ADDRESS (��
Total No. AdditioO
I certify that In the performance of the work for which this Fixed Appliances Not Over 1 HP CITY T o. 0
permit to Issued, I shall not employ any person In any manner PERMT. W
so as to become subject to the Workeas' Compo on Laws. Renee L/Heater_D.W. (CANT
Oven Dryer_W.M._} " ADDRESS
–�Dat 7� Applicant – Top FAU _W.H. Z
Hood Fan _Other_ CITY Tel No.
NOTICE TO APPLICANT. If, after making th ificate of Disp. f—*� Room Air Cond✓ S� AO UC N
Exemption, you should become subject to the Workers' REQ.NUMBER Clear
Compensation provisions of-the Labor Code, you must forth- Power Apperaw a& Large Appliances DISTRICT NO. PROCE ED BY
with comply with such provisions or this permit shall be- Size&Type HP,KW, KVA,qr KVA S., O (j
deemed revoked Q
Up to 1 Incl.
Over 1 to 10 Incl. FINAL
LICENSED CONTRACTORS DECLARATION DATES VALIDATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL /
-9 (commencing with Section 7000) of Dhriilon 3 of the Buil- Over 100 BY
noes and Professiom.Code; and my license Is in full force and
effect. Services J
0-200 Amp. Under 600 V
License Number Lie.Class 201-1000 Amp.Under 6GO V
Contractor Data Over 1000 Amp.or Over 800 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I ■m exempt from the Contractor's Sign with One Branch Circuit
License Lew for the following reason (Section 7031.5, Buaf- Additional Sign Branch Circuits
noes and Professions Code): i7a 4
Misc.Conduks&Conductors
1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure L not intended or offered for sale (Section
7044, Business and Professions Code). '
CONSTRUCTION LENDING AGENCY
Thereby affh-m that there Is a construction lending agency
for the performance of the work for which this permit is So TL
issued(Sec. 3097,Clv.C.). PERMIT FE (Sub-Total) ��
Lender's Name • PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
I certify that I have read thls application and state that the TOTAL FEE a b
above Information Is correct.I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorise representatives of this County to enter upon
the abovo-mentloned pro!y for imp ti purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
tureo
f Perml ee Date