HomeMy Public PortalAbout11003 GREEN TREE LN_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insuv , or•a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.) ?I
Poli Nc(-A JnCompany ECL•1 m b 4l} FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. EACH NO. FEE ADDRESS
PY Y New Residential Bldgs. & Pools
Fl _ G /
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ $ LOCALITY
NEAREST
tion department. Multi-family Sq. Ft. CROSS ST. C7_v C,J
Residential Swimming Pools OWNER OR
Date '� Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS g
This section need not be com leted if the work involved b First 20
( p y Total No. Additional CITY Tel. No 7
the permit is for one hundred dollars ($100)or less.)
I certifythat in the performance of the work for which this PLAN CHECK
P APPLICANT
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 Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT S - (�
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.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY Tel. No.
Hood Fan _Other_
LICENSED CONTRACTORS DECLARATION _
Disp. Room Air Cond. LICENSE OR -7 Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER 3 /0
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PR SSED BY
and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances �� U � a
(J Size &Type HP, KW, KVA, or KVAR'
License Number .5r�7 _1� 7 Lic. Class �� Up to 1 Incl. FINAL
, ` Over 1 to 10 Incl. DATE ?s VALIDATION
Contractor ��� Cn t=
�Date V Lt I11�- Over 10 to 50 Incl. FINAL C-
4J
E]
I am exempt under Sec. Over 50 to 100 Inc. BY �
Over 100
B.BP.C. for this reason
Date: Services, Swbd., MCC& Panelboards
0 -200 Amp. Under 600 V'
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maini. Elect. Over 1000 Amp. or Over 600 V
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)_ 2`�LI 5 A
7044, Business and Professions Code). ► # o o o a o 2
CONSTRUCTION LENDING AGENCY ° 1 0 Q 5 8
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.). a ° ° 1 0 0 5 8 r
PLAN CHECKING FEE 0 62.7-85
Lender's Name
PERMIT ISSUING FEE
Lender's Address O
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-mentioned perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign t e of Oermittee Date