HomeMy Public PortalAbout11002 GREEN TREE LN_Electrical__ WORKERS'C have ATIONAcate of
CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm, that ad have a certificate of'consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800,Lab• C.)
Polic dC {�t'!_oflrtTT .mpanyS�k L'_)J �`�1 FOR APPLICANT 70 FILL IN JOB
LZ Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
1 & 2-Famil S Ft. — LOCALITY
Certified copy is filed with the county building inspec- Y q• _ $ — $ e
NEAREST
tion department. Multi-family Sq. Ft. � �:2 d C`
o
Residential Swimming Pools CROSS ST.
Date ���
�� A'pplicant C OWNER OR
FIRM NAMM
E
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw. MAIL
.COMPENSATION INSURANCE ADDRES6\
This section need not be completed if the work involved b Add 20
( p Y Total No. � CITY � � )` Tel. No.-�.,-
the permit is for one hundred dollars ($100)or less.) Additional
I certify that in the performance of the work for which this APPLICCANTK
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY 7e1. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT n --
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT - ti
Exemption, you should become subject to the Workers' Range— Heater—D.W. — �
1 Compensation provisions of the Labor Code, you must forth- Oven — Dryer W.M._ ADDRESS
I with comply with s provisions or this permit shall be Top, — FAU —W.H. —
deemed revoked. CITY Tel. No.
LICENSED CONTRACTORS DECfLARATION Hood _ Fan _Other_ /
LICENSE OR
Dis _ Room Air Cond. `� -C/� C-
(commenting
hereby affirm that I am licensed under visions of Chapter 9 p' REG. NUMBER Class.
(commencing with Section\7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. P ED BY.
and Professions Code,and my,license is in full force and effect. D ( �.
Size &Type HP, KW, KVA, or KVAR' O
License Number +� Lic. ClTass —(� Up to 1 Incl. FINAL
Contractor 0 CO. � 1 Ilii _ Over 1 to 10 Incl. DATE �' VALIDATION 0
atEa U Over 10 to 50 Incl.
❑ I am exempt under Sec. Over 50 to 100 Inc. BY BY
B.&P.C. for this reason Over 100C�
Date:
Services, Swbd., MCC & Panelboards ► Z
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole& Appurtenances
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)_
7044, Business and Professions Code). , 22 3 4,4 A
CONSTRUCTION LENDING AGENCY # o o o o o 2
1 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) cya0 10 Q 5 8
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE 0 0 1 0058=0
Lender's Name
PERMIT ISSUING FEE 0627-85
Lender's Address
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 above-mentione pr perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa ulp of Permittee Date