HomeMy Public PortalAbout5743 KAUFFMAN AVE_Electrical__ WORKERS'COMPENSATION DECLARATION -603 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT _
1,_#!��Oby affirm that I have a certificate of consent to self insure,
61�a„certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof (Sec. 3800,Lab.C.)
PolicytN%___Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs.& PCMI
❑ & 2-Family, — $ ZVI
LOCALITY
Certified copy is filed with the county building inspection Sq.F $ ,
department. Multi-family Sq. Ft. — NEAREST
CROSS ST.
Date Applicant
Residential Swimming Pools OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Re Light JL Sw. MNAME
AIL°� 3L
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CIT Tel.No. �- 7��/
I certifythat in the performance of the work for which this permit PLAN CHECK
P P APPLICANT ��iy
is issued, I shall not em loy any person in any manner so as to p
ecome su ject to the ers'Compens o Laws. r Lighting Fixtures First 20 ADDRESS 5
i Total No. Additional CITY Tel.No.��i
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after m i is Certificate of PERMIT
Exemption,you should become subject he Workers'Compensation Range_ Heater D.W. APPLICANT /� .
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. _ CITY Tel.No. '3
LICENSED CONTRACTORS DECLARATION Hood Fan Other_
I hereby affirm that I am licensed under provisions of.Chapter 9 Disp. — Room Air Cond. LICENSE R
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Class.
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO.�/ PROCE D
Size& Type HP,KW,KVA,or KVAR U
License Number Lic.Class Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE �3���✓ VALIDATION O
Contractor Date Over 10 to 50 Inc]. FINAL, V
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
Over 100
B.&P.C.for this reason N
Services,Swbd.,MCC& Panelboards
Date: =;w,- 0- 200 Amp.Under 600 V
Poo-
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 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that 1 am exempt from the Contractor's License Law ACCT
8
ts
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuins
ip�I,
3M7 a��
X as owner of the property,will do the work and the structure Misc.Conduits & Conductors ITM
a�,GG11f�
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , y�,O1YwL
and Professions Code). ICLMfI� 75.50
CONSTRUCTION LENDING AGENCY CHECK 75.50
I hereby affirm that there is a construction lending agency for the rtf��tt
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHAMIGE.... •W.► '
Civ.C.).
PLAN CHECKING FEE �+ 7f+t,�
Lender's Name PERMIT ISSUING FEE [ 1 pMa7 vry7
Lender's Address .� .�.. 4481 1 AM10:21
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 wiring, and hereby authorize
representatives of his County to enter upon the above-mentioned
propert o do purposes.
IWO SEE REVERSE FOR EXPLANATORY LANGUAGE
ign r Permittee Date