HomeMy Public PortalAbout6121-6135 GOLDEN WEST AVE_Electrical__ ( WORKERS'COMPENSATIONDECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT'
L� CE-806G (2-80)
1-hereby affirm-that I have a certificate of consent to self COUNTY OF LOS ANGELES j BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or 1
a certified'copy thereof(Sec 3800,Lab C)
FOR APPLICANT TO FILL IN Mpg . L
Policy No Company EACH NO' FEE ADDRESS(17101,7-
New Residential Bldgs &Pools•
Certified copy is hereby furnished 1 &2-Family,Sq Ft $ — $ LOCALITY
❑ Multrfamily Sq Ft — NEAREST
Certified copy is filed with the county building inspection Residential Swimming Pools 'CROSS ST
department. OWN WOR
FIRM NAME
Date Applicant Outlets Rec'LLight—L Sw �JQ AMAIL
DDRESS ,
h First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No 7 Additional CITY Tel No
COMPENSATION INSURANCE
- - PLAN CHECK a
(This section need not be completed if the work ,involved APPLICANT 0
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS U
Total No Additional
I certify that in the performance of the work for'which this Fixed Appliances Not Over 1 HP CITY Tel No O
permit is issued, I shall not employ any person in any manner PERMIT U
so as to become subject to•the Worker ' Co p nsation Laws Range_ Heater_D W APPLICANT W
(� Oven_ Dryer_W M._ ADDRESS (n
Date O Applicant &kd Top _ FAU. _W H Z
Hood Fan _Other— CITY62 M&4
TeI No
NOTICE TO APPLICANT If, after making this Cer ficate of Disp _ Room Air Cond. LICENSEOR �I
Exemption, you should become subject to the Workers' REG NUMBER QClass
'Compensation provisions of'the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO PROCES ED BY,
with comply with such provisions or this permit shall be Size&Type HP, KW, KVA,or KVAR
deemed revoked Up to 1 Incl
FINAL
Over 1 to 10 Incl DATE 17
LICENSED CONTRACTORS DECLARATION ( 'VALIDATION
Over 10 to 50 Incl
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 � 7
License Number Lic Class 0-200 Amp Under 600 V
201-1000 Amp Under 600 V
Contractor Date 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)— �,Q 1 8 3 A,
structure is not intended or offered for sale (Section
7044, Business and Professions Code) #
CONSTRUCTION LENDING AGENCY o 1 Ia.o'?.
l0 0 2
I hereby affirm that there is a construction lending agency . `
for the performance of,the work for which this permit is 1 �'QQ
issued(Sec 3097,Civ C) PERMIT FEE (Sub Total) 0 0 0 [J Q'Q
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE fi �;7,'0 2—.8 1
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 repre entatrves of this County to enter upon
the bov - nU ed r p rty for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
�l
ignature of Permittee Da