HomeMy Public PortalAbout5343 GLICKMAN AVE_Electrical__ WORKER S'COMPENSATION DECLARATION
CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
CE-806
I hereby a-ffirm that I have a certificate of consent to self COUNTY OF LOS ANGELES (' BUILDING AND SAFETY
insure; or a certificate of Workers'Compensation Insurance,or
a certified 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. $ $ LOCALITY zrq
_ I
F-1certifiedSq. Ft. NEAREST
Certified copy is filed with the county building inspection CROSS ST �tJ
department. Residential Swimming Pools OWNER OR j,
FIRM NAME i. v®
Date Applicant Outlets: Rec.—Light—Sw. MAIL
First 20 ADDRESS 'rZ7
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No4/
COMPENSATION INSURANCE
PLAN CHECK
APPLICANT
(This section need not be completed if the work involved Lighting Fixtures First 20 0
by the permit is for one,hundred dollars ($100) or less.) ADDRESS �
Total No. Additional
I certify that in the performance of the work for which this .CITY Tel No ]-
Fixed Appliances Not Over 1 HP U
permit.is issued, I shall not employ any person in any manner PERMIT i LU so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT E ! 'rte CL
' Oven = Dryer_W.M._ ADDRESS U)
� �
/KD
ate! — '.Z Applicant Top FAU _W.H.. V
' Hood Fan _Other_ CITY u Tel No. _ r
NOTICE TO APPLICANT: If, after ma ing this Certificate of Disp. Room Air Cond.— LICEEOR
Exemption, you should become subject to the Workers' REG.NUMBER U Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW, KVA,or KVAR
Up to 1 Incl 'C J
FINAL
Over 1 to 10 Incl. DATE X*'
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. VALIDATION
rI hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY e
ness and Professions.Code, and my license is in full force and
effect. Services
C_ 0 200 Amp. Under 600 V I -
License Number D Lia Class '
�. 201-1000 Amp. Under 600 V q /�
e-
Contractor4eC Date 4 f7— 2 Over 1000 Amp,or Over 600 V Loo
7
HOME 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, Busi- Additional Sign Branch Circuits `Y5 5 6 A
ness and Professions Code):
Misc.Conduits&Conductors (#? 0 0 0 0 o 2
I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)=
structure is not intended or offered for sale (Section 2 0 - 23,50
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY c.
I hereby affirm that there is a construction lending agency o 0 0 2 3' 0
for the performance of the work for which this. permit is PERMIT FEE (Sub-Total) 0 iI- 07—82
issued(Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE SC
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
hereby authorize representatives of this County to enter upon
the bove, entioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
,�"ignature of mittee Date