HomeMy Public PortalAbout10342 KEY WEST ST_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRfCAL PERMIT
11 hereby affirm that 1 have a certificate of consent to self CE-806G �j
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY ILfI
or a certified copy thereof (Sec. 3800, Lab. C.) lip y' -2-
Policy
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. 8 Poo
EACH I NO. FEE ADDRESS Z• 6� ���
ertified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ Q —Is 719 LOCALITY j If CC
NEAREOSSST
on department. �`� Multi-family Sq. Ft. —
Date
/ 23 V r-Applicant „'4 `4 '�`�c Gl, Residential Swimming Pools OWNER OR
FP FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw. MAIL
COMPENSATION INSURANCE First 20 '' a ' ADDRESS
(This section need not be completed if the work involved byTotal No ' t CITY Tel. No.
.
the permit is for one hundred dollars ($100)or less.) Additional
PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT �+ �� -�-
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT �� o A ` . T ci`a ci
Exemption, you should become subject to the Workers' Range_ Heater—D.W. t', r (�
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M. ADDRESS (
[ Z7.� s�v� ,,I
with comply with such provisions or this permit shall be Top _ FAU —W.H. — �.,
deemed revoked. CITY A6C yq$
(A Tel. No. 5
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
Room Air Cond. LICENSE
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. REG. NUMBER 3'��,9rT� Class.
(commencing with Section 7000) of Division 3 of the Business ppDISTRICT NO. PROCESS o
Power Apparatus 8 Large Appliances
and Professions Code, and my license is in full force and effect. O
Size &Type HP, KW, KVA, or KVAR' f Z
License NumberLic. Class —�� Up to 1 Incl. FINAL O.
Apcb,&A t� 23 �6tS' Over 1 to 10 Incl.
DATE / ���
Contractor Date � v VALID TIOPI 0
❑ Over,10 to 50 Incl. FIN W
I am exempt under Sec. Over 50 to 100 Inc. BY j
B.&P.C. for this reason Over 100 Z
Date: Services, Swbd., MCC & Panelboards
0 -200 Amp. Under 600 V
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 3 2 8 3 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit # 0 0 0 0 0 2
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and ( 0 - 87. 1 4Professions Code):
csi
I, as owner of the property, will do the work and the. Misc. Conduits & Conductors 0 0 08 7.1
4
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ►
7044, Business and Professions Code). ) 0,24 =85
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 1
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 '
thea ve-mentione pG�/7"`� for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
1Q�y3�5
gnat/ of Permittee Date