HomeMy Public PortalAbout9189 JAYLEE DR_Electrical_10/8/1991_outlets,fixtures WORK¢RS'COMPENSATION DECLARATION - 10/81
CE-806G APPLICATION
2®R ELECTRICAL
ECTRICAL P2RMIT
'
I reby,atfirm that.I have a certificate of consent to self insure,
o,a c'tifigate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDINGAND SAFETY
copy,th6reof(Sec.3800,Lab.C.)
Policy No. +Company'. - FOR APPLICANT TO FILL IN 'JOB
Certified copy is hereby furnished., New Residential.Bldgs..& Pools EACH NO. FEE ADDRESS a (�
Certified co 1 & 2-f amity,Sq.Ft. $ — $ LOCALITY �� + C O�'�fltje YtiCaee
-, copy is filed with the county building inspection — .
NEAREST.
department. Multi-family Sq:Ft. • CROSS ST. : - 07"CIL
Date Applicant'' Residential Swimming Pools OWNER OR " '• ,
FIRM NAME I`GL-_GZ. L eZle�
CERTIFICATE OF EXEMPTION FROM WORKERS U S '6c `� MAIL
Outlets:Re Light Sw. �'�' ADDRESS ' S/4YV1
COMPENSATION INSURANCE o
First 20,
permit is-.for one hundred dollars ($100)or less.) Total No. Additional _ -
(° •. �� PLAN CHECK -
I certify'that,in the performance of the work for which this permit APPLICANT
is Lissued, I shall,not.employ, any person,in-any manner so as to * �3; ADDRESS
become subject to the Workers'Compensation Laws. Lighting Fixtures First-20
Additional
Total No. A:57onaCITY Tel No
Date. Applicant Fixed Appliances Not Over 1 HIP
NOTICE, TO APPLICANT: If, aftemaking this Certificate of PERMIT
r•
_ Heater_ D.W. APPLICANT BC�C
Range
. Exemption,you should become subject to the Workers'Compensation g
provisions.of,the.Labor Code,,you must forthwith comply with such .Oven Dryer. W.M. ADDRESS
provisions or this permit shall be deemed revoked Top. «_= FAU•. W.H.
LICENSED CONTRACTORS DECLARATION.' Hood Fan Ofher
CITY o.
— � _ "�J
I hereby,affirm that I am licensed'under.provisions'.of•Chapter 9 Disp. Room
Air CoCond. O LICENSE OR
"
(commericing with Section 7000) of Division 3 of the Business and REG.NUMBER ' Class
Professions:Code,and my license is in full force and effect. DISTRICT NOPF40CESSED BY..
, ..Power Apparatus 8 Large Appliances ,_.
M,
Size&Type.HP,KW,'KVA,or KVAR B Op p
License Number Lic.Class Up to 1 Incl. - FINAL U_
Over 1'to'10 Incl.• DATE 0
Contractor' DateZ l Z VALIDATION^
Over 10 to 50 Incl FINAL �"
I am exempt under Sec. Over 50 to 100 Inc. BY ,• W
B.&P.C.for this reason Over 100 N'
Services,Swbd.,MCC& Panelboards
Date: -
0.- 200 Amp.Under 600 V 264 _J �
Signature 201'-,1000 Amp:Under600 V v
❑ Over 1.000 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 Contractors,License Law `T r•
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits A'=' _
' Code):
Misc Conduits& Conductors -
I,as owner of the property,will do the work and the structure a 1 E, c
is not intended or offered for 'sale.(Section 7044, Business Other,(See Complete Fee Schedule) -
tf
and Professions Code).
• it
D S._t I HL. 3,,•_ ,_
CONSTRUCTION LENDING AGENCY CHECKi7z"
I hereby affirm that there is a•construction lending agency for the
performance of'the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) a i11 '•�t a ! '
Civ.C.).
PLAN CHECKING FEE
Lender's Name I i=_j1101 6 4CI1_f i I1_ S t�i
PERMIT ISSUING FEE
Lender's Address '{'r
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree'to comply with all County ordinances
and State laws regulating`Electrical g, and hereby authorize
representatives of this County to en r pon the above-mentioned
ope ty for inspec' purpo s.
�� 9^1 j SEE REVERSE FOR.EXPLANATORY.LANGUAGE .
, ' 4&
gnature of Permiltee Date