HomeMy Public PortalAbout6100 IVAR AVE_Electrical__ .'-W{9RKERS',COMPENSATION DECLARATION CE-806G (2-80) APPUCAMN FOR ELECTMCAL PUNT . '
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I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
"insure;or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
FOR APPLICANT TO FILL IN
Policy No. JOB
Company' EACH NO. FEE ADDRESS (V0 00
New Residential Bldgs. ools
Certified copy is hereby furnished.. 1&2-Family,Sq. Ft. MOO $' — $ LOCALITY,
OMulti-family Sq. Ft. NEAREST
Certified copy is filed with.the county building inspection �. CROSS ST V
department., Residential Swimming Pools 4 _ OWNER OR '1
�e� FIRM NAME
Date Applicant Outlets: Re�Light_a�,Sw.13— AMAIL
DDRESS v��• �g -
First 20
CERTIFICATE OF,EXEMPTION FROM WORKERS' Total NO.15 I Additional CIT �], Tel No. }
COMPENSATION INSURANCE O
' PLAN CHECK O-
APPLICANT
(This section need not be completed if the work involved Lighting Fixtures First 20 A U
by the permit is for one hundred dollars.($100) or less.) ADDRESS
Total No. s Additional 0
I certify that in the performance of tfie work for ich thisCITY No. l—
Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any person.in a manner PERMIT. W
so as to become�ibject t he Workers'. o s on aws. Range_ Heater_D.W.. I APPLICANT ;' p
L�`J Oven _ Dryer_W.M._ ADDRESS
Z
Date Applican Top — FAU —p W.H.
R — - .
Hood Fan Other_ CITY Tel No.
NOTICE TO APPLICANT: f, after making this erti icate of Disp. Room Air Cond.— .� ICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances. DISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR
Up to 1 Incl. . �"
FINAL
Over 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION- Over 10 to 50 Incl., ✓ VALID TION
I hereby affirm that I am licensed under.provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000 of Division 3 of the Busi- BY
( g ) Over 100
ness and Professions.Code,-and my license is in full force and z 2 7 `a 2 A
effect. Services
License Number Lic.*Class 0-200 Amp..Under 600 V
# 0 0 0 0 0 2
201-1000 Amp.Under 600 V
Contractor Date, Over 1000 Amp.or Over 600 V Jo o73.25
r
HOME OWNER-BUILDER,DECLARATION Temp. Power Pole&Appurtenances o- 73,255,
Sign with One Branch Circuit
I hereby affirm that I am,exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits 0 8.2 Q_8 5
nes and Professions Code):
Misc.Conduits&Conductors
I; as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency "
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.).
Lender's Name PLAN.CHECKING FEE (One-Fourth Permit Fee)'
Lender's Address PERMIT ISSUING FEE U
I certify that I have read this application and state that.the TOTAL FEE 7
above information is correct.I agree to comply with all County
ordinances aSt ate ws regulating Electrical wiring, and
hereby autho i e re re tatives of this County to enter upon
he abov me i e p per ^for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
A At it
ature o r e ' Date