HomeMy Public PortalAbout5611 GOLDEN WEST AVE_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806G 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self - 6 ,,
insure, )�a,ctrtifnca�e of'#VoRkers' Compensation Insurance, ' COUNTY OF LOS ANGELES 7—,C. r BUILDING AND SAFETY
or a certlFied copy thereof (Sec 3800, Lab C ) c
Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS ,.7 tP ��/�/C��i 6V C
❑, Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
❑ 1 & 2-Famil S Ft — LOCALITY
Certified copy is filed with the county building mspec- y' q $ — $ NEAREST / �
tion department Multi-family Sq Ft CROSS ST G., %VC
Residential Swimming Pools OWNER OR
Date Applicant
FIRM NAME ee4 i AwC
CERTIFICATE OF EXEMPTION FROM WORKERS' O
' Ri IL
uTlets ec Light Sw
COMPENSATION INSURANCE ADDRESS tt
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s section neenot completed if the work involved b First 20
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p Y Total No l nTel No
Additional CITY ��
the permit is for one hundred dollars (S100)or less.) AddiPLAN CHECK
I certify that in the performance of the'work•for which this PLANCHET -
permit is issued, I shall not employ any person in any manner , 3 2
so as to become subject to the Workers'Compensation Laws Lighting Fixtures First-20 ADDRESS -
f pgo J _ /� /"f Total No _ Additional CITY Tel No
Date Applicant CifT s7 GSL Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO PLICANT If, after making this Certificate of APPLICANT
Exemption, you should become subject to the Workers' Range__Heater_D W' —
Compensation provisions of,the Labor Code, you must forth- Oven _ Dryer W M ADDRESSP
with comply with such provisions or-this permit shall'be Top _ FAU _WH _
deemed revokedCITY ,Zf'C /-, ,/ Tel No
LICENSED CONTRACTORS DECLARATION Hood _ Fan —Other— LICENSE OR /
I hereby affirm that I am licensed under provisions of Chapter 9 Disp Room-Air Cond REG NUMBERClass
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO PROCES D-BY >,
and Professions Code,and my license is in full force and effect tL
/ Size &Type HP, KW, KVA, or KVAR Q
License Number 3L� 67 3 Lic Class Up to 1 Incl FINAL` V
J DATE ��� W
Over 1 to 10 Incl VALIDATION Q
Contractor ���«/s �/& Date Over 10 to 50 Incl
FINAL
V
❑ I am exempt under Sec Over 50 to 100 Inc BY ar �"> 4..t.w1� 2 3 2 5 0'A W
d
B &P C for This reason Over 100 ► / 6 6 5 # 0 0 0 0 0 2
' Services, Swbd , MCC& Panelboards (� 1 • ' `,`,
Date ' 0 -200 Amp Under 600 V 2 0 o,,3 9.0 0
Signature 201 - 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V :o 0 0 3 9,b 0
Exemption for Reg Maint Eject
f
SINGLE FAMILY Temp Power Pole & Appurtenances _ 0 29-83
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
-Law for the following reason (Section 7031 5, Business and
Professions Code)
❑ .I, as owner of the property, will do the work and,the Misc Conduits& Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— Poo7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY -
I hereby,affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec 3097, Civ C )
PLAN CHECKING FEE-
Lender's Name
Lender's Address
PERMIT ISSUING FEE (� _
.. � 6 '
I certify thatll have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County ,
ordinances and State jaws regulating Electrical wiring, and
hereby authonze're resentatives of this County to enter upon
the above-menti d operty for inection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
40'- J*7j
atu a of Per -be Date