HomeMy Public PortalAbout11007 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
irlsure,,or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
fl1
Poli IN 6-n�"ompany FEC' i�as0w1� FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools
EACH NO. FEE ADDRESS
❑ $ _ g LOCALITY _
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft.
tion department. Multi-family Sq. Ft. — NEAREST
p CROSS ST. �.�
Date `�� Applicant �+� Residential Swimming Pool; OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
First 20
(This section need not be completed if the work involved by Total No. Additional CITY `fes Tel. No. "�
the permit is for one hundred dollars($100)or less.)
PLAN CHECK
I certify that in the performance of the work for which this 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 R� V3
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. Hood _ Fan _ Other_ CITY Z � Tel. NoCC'��
LICENSED CONTRACTORS DECLARATION LICENSE OR
hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class. C
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. P SSED BY
and Professions Code,.and my license is in full force and effect. EL
Power Apparatus& Large Appliances r
Size &Type HP, KW, KVA, or KVAR' (�3 O
License Numbber.`�79-inti Lic. Class Q"� Up to 1 Incl. FINAL k)
f'1 ` � �IOver 1 to 10 Incl. DATE VALIDATION
Contractor Date.. IU NC. Over 10 to 50 Incl.
FIN �
❑ I am exempt under Sec. Over 50 to 100 Inc. BY L&I
B.&P.C. for this reason Over 100
Date: Services, SWbd.,-MCC & Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp.' Under 600 V
❑ Exemption for Reg. Maint. 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, wiJI do the work and the Misc. Conduits 8 Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ -92_234,6.A[.
7044, Business and Professions Code). Poo #,o o o o o 2
CONSTRUCTION LENDING AGENCY
�l hereby affirm that there is a construction lending agency for I- o 9&58
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). ° C - 9&5 8,5
PLAN CHECKING FEE 0627-7-85 2 7—8 5
Lender's Name
PERMIT ISSUING FEE Liz
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 ave-mentioned apopNty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa u� of Permittee Date