HomeMy Public PortalAbout11026 GREEN TREE LN_Electrical__ i
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 copy thereof (Sec. 3800, LL�db. C. 'c
POII NC7.A k2(+ Company--t C LR m mXS+ FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. EACH NO. FEE ADDRESS
copy ' y New Residential Bldgs. & Pools
❑ 1 & 2-Family, S Ft. $ _ $ LOCALITY
Certified copy is filed with the county building inspec- Y, q
tion department. Multi-family Sq. Ft. .-^^22NEARE
ROSSSST. G�-
Residential Swimming Poolst
Date & Z Applicant �� FOIRM NAME
WNER OR `. C '�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS `
This section need not be completed if the work involved b First 20
( p Y Total No. CITY Tel. No.
the permit is for one hundred dollars ($100)or less.) Additionah. 1, t '
I certifythat in the of the work for which this PLAN CHECK
e performance 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
Additional
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT mc
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 Tel. N
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. P SED BY
and Professions Code,and my license is in full force and effect.
1�7 Size &Type HP, KW, KVA, or KVAR' Q O
License Numberv2J9- -2'-1 Lic. Class10 Up to 1 Incl FINAL 3 U
DATE �
Over 1 to 10 Incl. VALIDATION .
Contractor �5� ��c> �1>�•Dat�1L)�'� Over 10 to 50 Incl. FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. By
;&
for this reason Over 100
Date:
Services, Swbd., MCC & Panelboards ►
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)_ , 2 2 3 4,2 A
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY # o 0 0 0 0 2
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) 1.o 1 O 4 G 2
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE - 104,020:5
Lender's Name
0 =
PERMIT ISSUING FEE 6,27 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
he abve-mentioned p pert�or inspection purposes. _ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signat r 'o Permittee Date 4