HomeMy Public PortalAbout6052 KAUFFMAN AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION
CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
CE-806
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, ab. C.) v"A iVT�+` �*t AVENUE
Po icy �L— Compa FOR APPLICANT TO FILL EACH N JOB
NO. FEE ADDRESS -6�K�U F1'Itfl\ AVEN E
New Residential Bldgs.&Pools
❑ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY TEMPLE CITY, CA
Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department. ^ Residential Swimming Pools OWNER OR �,�p
�� . /I/4J}'�(.� Z�. l FIRM NAME lam• & MRS. HEVNER
Date Applicant, � Outlets: Rec. Light_ Sw. MAIL
First 20 ADDRESS 6025 KAUFFMAN AVENUE
CERTIFICATE OF-EXEMPTION FROM WORKERS' Total No. Additional CITYTEMPLE CITY Tel No-286- 6645 }-
COMPENSATION INSURANCE PLAN CHECK
APPLICANT- O
(This section need not be completed if the work involved Lighting Fixtures First 20 U
by gg ADDRESS
the- permit is for one hundred dollars ($100) or less.) Additional
Total No. O
I certify that in Fixed Appliances Not Over 1 the performance of the work for which this HP CITY Tel No. U
ermit is issued, I shall not em
p pto y any person in any manner PERMIT d
so as to become subject to the Workers' Compensation Laws. Range_ Heater D.W. APPLICANT MiRALES ELECTRIC Ow,.
Oven _ Dryer_W.M. ADDRESS 8843-._MISSION.-DRIVE z
Date Applicant Top _ FAU _W.H.._ M An O
Hood _ Fan _Other_ CITYROSEMEAD -^ .. . .TeII No. 820-4260
NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond._ LICENSE 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. 7POC�EED 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 J.
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE � + VALIDATION
Over 10 to 50 Incl.
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- Over 100 BY
ness and, Professions.Code, and my license is in full force and
effect. ))� Services �'
5-0
License Number/17-71W 1� Lic. Class U 0-200 Amp. Under 600 V
/r` 201-1000 Amp. Under 600 V G!�✓""
Contractor/ '/�!�4�J kl IfAtate � d V Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I he affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits&Conductors'
, as owner othe property, wdo the work and the E] 1, of ill hh
Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY # �. C
I hereby affirm that there is a construction lending agency C
for the performance of the work for which this permit is Q PERMIT FEE (Sub-Total) '2 0 -'2' 5 0
issued Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 0 0 o 2 0.5 0 5)
Lender's Address PERMIT ISSUING FEE 09,24-80
1 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 represe i es of this County to enter upon
the above-mentionpr / for
f in tion purposes
SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permit a to