HomeMy Public PortalAbout9507 GARIBALDI AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION CE-806G (2-8Q) APPLICATION FOR ELECTRICAL PERMIT -
I hereby affirm that I have ■ certificate, of cobsent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certlflGate of Workers'Compensation Innu&nce,or
'a Certlfled copy theceof'(Sec. 3800,Lab.C.)
Polley No.TTCompany FOR APPLICANT TO FILL IN JOBS►/►`) r
New Residential Bldgs.&Poole, EACH NO. FEE ADDRESS Y
Certlfled copy is hereby furnished. 1 &2-Femlly,Sq. Ft. $ — $ LOCALITY
le
Multi-family Sq. Ft. tLEAREST
Certified-copy b filed With the county bullOIng inspection CROSS ST
departimant. Residential SwimmJhp Pool@ OWNER OR /^ 04� i
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FIRM NAME CA Ojee,41Z
Date A.ppllcant_ Outlets' Rec._Light Sw. MAIL
�irrt 20 ADDRESS Q
CERTIFICATE QF EXEMPTION FROM WORKERS' T6tel No. . Additional CITY � Tel No.Zd
COMPENSATION INSURANCE PLAN CHECK
('Phis sectkm peed not becompleted IS the wort h olved APPLICAN
by the permit is for opo hundred doRm (;100) or—leis.) Lighting Fixtures First 20 ADDRESS
Total No. Additional
I cprttfy that In the performance of the work for Which this Flked Appliances Not Qver 1 HP CITY Tel No.
Permit Is issued, I shall not employanpe
y rson Ian er PERMIT
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so as to.become,subject to the e o� RanAr D.W.
e� Heate _ W CANT >e Z
,.[) Oven Dryer_W.M.` ADDRE88
DataApplicant ��'` Top _ FAU —W.H.
Hood — Fen _Other_ CITY Tel No.,
NOTICE TO APPLICANT: If, after making this Certificate of Dlsp.' _ Roon+Air Condom: CENSE OR 3q
Exemption, you should become subject to the Workers' —.REQ,NUMBER T few C`
t<ompmuatiop provWonr of the Labor Code,ypu most forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESS-ED 13Y
with comply with such provision or this permit shalt be
deemed revoked Size&Type HP,KW, KVA,or KVAR K
Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE .VALI DATION •,
LICENSED CONTRACTORSpECT.ARATION � OO� T
C+v9r 10 to 60 InCI.
I hereby afnrM that I am lkenied under provWons of ChapterOver 60 to 100 Inc. FINA,
9 (comm6pctn9 with Section 7000) of Dtvidon 3 of the Bus!- —� Over 100 BY
noel and Ptofesalons.Code, and my license.is in full force,and
effect. Sefvlpea
��(? 0-200 Amp. Under 600 V
License Number LIC.Class 201-1000 Amp. Under 600 V
Contractort 1AJr!ejer Date_�� '•Ovar 1000 Amp.or Over 600 V
r HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances. ,
I hereby efl}rpa that I am a em Sign with One Branch'Clrcult
I pt.from the 031.5, Buil- Additional Sign Branch Circuits'
License Law for the fofigwins reason (3ectbn 7031.5, Buil- '
nein and Professions Code):
Mlsc.Conduits&Conductors �'Jr 3 2'A
Q I, u owner of the property, will do the work ted the Other(See Complete Fee Schedule)—
structure tv-not intended or offered.-for sale (Soc4oa # o 0 0 0 0.2
7044, Business and Professions Code).
CONSTRUCTION LENDING A-QENCY 2,e -3,5.50
I hereby affirm that there L a coristructiop lending agency
for the; perforWance of the work fot which this pgrrhlt L pERIy11T FEE (Su�Totel) �o oro
issued(sec.3097,CIV.c.). 3 a 50-2i
Lender's Natne PLANCHECKING FEE (One-Fourth Permit Fee) 0.a O 3L e,',2
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and stafe that the TOTAL FEE
above igformation is correct.I agree to comply with&II CouWy ti
ordinances and State laws regulating Electrical wiring, and
hereby authorise representathros of this County to enter upon E -
the ao-mentioned rope for Inspection purposes. SEE-REVFRSE FOR EXPLANATORY LANGUAGE
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Signa o Permittee Date