HomeMy Public PortalAbout5507 GOLDEN WEST AVE_Electrical__ WOI:S'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have 'a certificate of consent to self COUNTY OF LOS ANGELES BUILQ!NG AND SAFETY
insure, or a certificate of Workers'-Compensation Insurance,or
a certified copy thereof Wec. 3800, Lab. C.) '
Iq f'_ad ��� Com � ' FOR APPLICANT TO FILL IN JOB ��//''��
Poli pan ,�� (`:, �.�rl�� EACH NO. FEE ADDRESS��.7�J
New Residential Bldgs.&Pools
❑ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALIT
Multi-family Sq. Ft. — NEAREST _
WCertified copy is filed with a unt building inspection CROSS ST
department. Residential Swimming Pools OWNER O
FIRM NAM
Date Applicant Outlets: Rec._Light_Sw. MAIL ,/
First 20 ADDRESS t° OJ--
/ CERTIFICATE OF EXEMPTION FROM WOR 'RS' Total No. Additional CITY ` Tel No.
}' COMPENSATION INSURANCE PLAN CHECK °' d
(This section need not be completed if the work involved APPLICANT O
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS U U
Total No.
Additional cc
O
Fixed Appliances Not
I certify that in the performance of the work for which this Over 1 HP CITY Tel No. F.
U
permit is issued, I shall not employ any person in any manner PERMIT
so as to become subject to the Workers' Compensation Laws. Range_ HeatertL_D.W. APP LI CAN W
Oven Dryer_W.M. ADDRE ^ rn
Date Applicant ' Top — FAU _W.H.,_ ` �
Hood _ Fan _Other_ CITY /-� A—r-, Tel N� ���
NOTICE TO APPLICANT: If, after making this,Certificate of Disp. _ Room Air'Cond-_ LICENS OR e
Exemption, you should become subject to the Workers' REG. NUMBER CIass
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.
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE
Over 10 to 50 Incl. ��` VALIDATION
I 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
ness and Professions.Code, and my license is in full force and
effect. Services
License Number '���"� iia Class�� 0-200 Amp. Under 600 V
�
j g 201-1000 Amp. Under 600 V
s 1
Contractorgtjk, T 4A ,gate ~ Over 1000 Amp.or Over 600 V
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
ness and Professions Code):
Misc.-Conduits& Conductors
❑ I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— �9 0''1 .3
structure is not intended or offered for sale (Section
7044, Business and Professions Code). fY /,,00.
�kc`V
2
CONSTRUCTION LENDING AGENCY (((((I hereby affirm that there is a construction lending a cy 2
for the perfor ante of thy? ork for which this pe mill is PERMIT FEE (Sub-Total)
issued (Sec. 30C
Lender's Nam (� v
,�'� PLAN CHECKING FEE (One-Fourth Permit Fee) 2
Q�6. 1 1 8 1
Lender's Address ISSUING FEEI certify that I have read this application and state that thetRMIT
TAL FEE r 0 0 Fo �
above information is cor ect. I agree to comply with all County ¢� 0 0 0 NO
ordinances and State I s regulating Electrical wiring, and /z �` 0 0' o O
hereby auth Sze cpres tatives of this County to enter upon /�i W C�1 0
the above- entio operty�for inspection purposes. 1 N N o �1
SEE'REVERSE FOR EXPLANATORY LANGUAGE Co O O o N
O O ND>
Signature of Permittee Date CH