HomeMy Public PortalAbout10336 KEY WEST ST_Electrical__ WORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby CE-806 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, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB , j�
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS !.c `�/
1 & 2-Famil q. $ — $ LOCALITY e-
�ertified copy is filed with the county building inspec- y, S Ft. e✓h' G�
tion depar ment. Multi-family Sq. Ft. — NEAREST
Date `Q Residential Swimming Pools CROSS ST
Applicant
A"ILP' . `'�'.•` c
OWNER OR NAME W`G-5Ca
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
First 20,
(This section need not be completed if the work involved by Total No. Additional CITY Tel. No.
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this 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
Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HIP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
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 ''L2—j YkJ
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. CITY Gpd ILA Tel. No. qq—)�77
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ j�
LICENSE
Disp. Room Air Cond. l
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER
Cass.BER 7i D V b 4C,-10
(commencing with Section 7000) of Division 3 of the Business power Apparatus& Large Appliances DISTRICT NO. PROC S BY a'
and Professions Code, and my license is in full force and effect. `� o
Size &Type HP, KW, KVA, or KVAR V C�
License NumA*�-�p��ber 3`24+ 6 Lic. Class G�4 G Up to 1 Incl. FINAL �.
+� £1 G'�. d,Z3 Over 1 to 10 Incl. DATE J Z VA ATION
Contractor.PDate Over 10 to 50 Incl. FINA v W
❑ I am exempt under Sec. Over 50 to 100 Inc. BY 11.
100
8.&P.C. for this reason Over Z
Date: Services, Swbd., MCC & Panelboards ►
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V 2 3 2 a 2 A
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. # o o o a 6 2
SINGLE FAMILY Tem Power Pole &Appurtenances
HOME OWNER-BUILDER DECLARATION pCiI ° o87. 1 4
1 hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits o o 0 8 7. 1 4 5
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors 1 0.24-1--85
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ►
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 issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
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
the ve-menti ned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signat of Permittee D to