HomeMy Public PortalAbout8848 GARIBALDI AVE_Electrical__ WORKERS'COMPEN$ATIONDECLARATION
CE-8D6G (2$0) APPLICATION FOR ELECTRICAL PERMIT
•` � r � CE�06
I hereby It rm that I have ■ certificate of consent to self COUNTY OF LOS ANG LES BUILDING AND SAFETY
Insure, or ■ certificate of Workers'Compensation Insurance,or
e certifled copy thereof(Sec.3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB
Policy No. Company New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. 3 3 LOCALITY (�
Certified copy Is filed with the county building Irupoctio❑ Multi-family Sq. Ft.
CROSS ST
department. Residential Swimming Pools. ORM NAME �L
Data Appltcant Outlets: Recl-Ll ht Sw. MAIL
�(``]]f7 irst ZF ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. 17 Additional CITY PLO CTTY Tel No. }
COMPENSATION INSURANCE PLAN CHECK a
(This sectlon need not be completed If the work involred APPLICANT 8
by the permlt is for one hundred dollars (5100) or lea.) Ughting Fixtures First 20 ADDRESS C7
M:Total No. Additional O
I certify that In the performance a work for which this Fixed Appliances Not Over 1 HP CITY Tel No. 0
permit h issued, I shall not amp a p n In.any manner PER T
to as to become subject to tti or n' mpensation Laws. Range_Heater D.W. _ PP ICANT W
-t Oven Dryer_W.M. ADDRESS O E L Z
05
Date ALplkcant Top _ FAU _W.H.
Hood Fan _Other_ CITY Pq Tel No-
NOTI E TO APPLICANT: If, after making this Certiflcate of Dlsp. _ Room Air Cond— LICENSE
Exemption, you should become subject to the Workers' REQ.NUMBER Clava
0-1
Compensation provisions of the Labor Code, you must forth- Power Apperatus& Large Appliances DISTRICT NO. P BY
with comply with such provtsioru or this permit shall be Size&Type HP,KW, KVA,or KVA / 'j�
deemed revoked. �/ e
Up to 1 Incl. FINAI,
Over 1 to 10 Incl. DATE y,/
LICENSED CONTRACTORS DECLARATION Over 10 to 60 Incl. /C U VALI DATIO
I hereby affh-m that I am licensed under provisions of Chapter Over 150 to 100 Inc. FINAL
9 (commencing with Section 7000) of Division 3 of the Buri- Over 100 BY
neu and Professiom.Code, and my license Is In full force and
effect. �` Services
Licen Number_3MM G Lic.Cla.a 0200 Amp. Under 600 V /• "
(]��� 201-1000 Amp. Under 800 V
Co trector�s/")b co,_ Data Over 1000 Amp.or Over B00 V
NOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Bus]- Additional Sign Branch Orcults
nets and Professions Code):
Misc.Conduits& Conductors
I, as owner of the property, wiII do the work and the Other(See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044, Business and ProfeWons Code).
CONSTRUCTION LENDING AGENCY
I hereby ■form that there is a construction lending agency
for the performance of the work for which this permit Is PERMIT FEE (Sub-Totes) 0 0 0 0 0 2
Issued (Sec. 3097,Civ.C.). 2 e -.29.50
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE o o o.2 9. 5 G
I certify that I have read this application and mate that the TOTAL FEE FJ 0 7. 24 -80
above to n Is correct.I agree to comply with all County
ord 6State laws regulating Electrical wiring, and
her y ■ut rise presentatives of this County to enter upon
th bov an ti ed oparty f Inspection purp 'SEE'REVERSE FOR EXPLANATORY LANGUAGE
Stgnaturo o PermitteeDate