HomeMy Public PortalAbout11010 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
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified
n copy thereof (Sec. 3800, Lab. C.)
Poli NV—PZ � 4�FCompana �� �Lk FOR APPLICANT TO FILL IN JOB �i
Certified copy is hereby furnished. fNew Residential Bldgs. & Pools EACH NO. FEE ADDRESS J a
❑ Certified copy is filed with the county building inspec- & 2-Family, Sq. Ft. $ — $ LOCALITY
NEAREST
tion department.� Multi-family Sq. Ft. CROSS ST.
�7^ � Residential Swimming Pools OWNER OR
Date / Applicant FIRM NAME 1 .
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.— MAIL �.
COMPENSATION INSURANCE First 20 ADDRESS ,
(This section need not be completed if the work involved by Total No. CITY Tel. No.
the permit is for one hundred dollars($100)or less.) Additional 1 } Cti l3
I certifythat in the performance of the work for which this PLAN CHECK
e 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
Exemption, you should become subject to the Workers' Range_ Heater—D.W. — S ��
Qr
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 1 Com, Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I 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. PR ED BY
and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances
Size &Type HP, KW, KVA, or KVAR' r62
License Nu ber_? /7 /Q'10� Lic. Class C_ Up to 1 Incl. FINAL
c� Over 1 to 10 Incl. DATE 7 _�` VALIDATION
Contractor •� (bate�U elf'— Over 10 to 50 Incl. J
FINAL �
❑ 1 am exempt under Sec. Over 50 to 100 Inc. BY
Over 100
B.&P.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. 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): �2 3 5 0 A
El1, 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)_ Poo # o a a a a 2
7044, Business and Professions Code). I o o 9 8 5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for o o 0 98,586
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). 0 627-85
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE ( S
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
lhn,erebuthorize representatives of this County to enter upon
e-mentioned _r. ertyfor inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
e o ermittee Date