HomeMy Public PortalAbout10380 KEY WEST ST_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663
CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES j BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
FOR APPLICANT TO FILL IN ,JOB
Policy No. Company EACH NO. FEE ADDRESS d W
New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family Sq. Ft. Jk6,? $• — $ L4 LOCALITY
Multi-family Sq. Ft. — NEAREST
Certified co Fn
Residential Swimming Pools
copy is filed with the county building inspection CROSS ST
department. OWNER OR
FIRM NAME
Date Applicant Outlets: Rec.—Light— Sw. MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No.
COMPENSATION INSURANCE PLAN CHECK }
a
(This section need not be completed if the, work involved APPLICANT O
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS U
Total No. Additional
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. F_
permit is issued, I shall not employ any person in any manner PERMIT '
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT MW Y N o",S o"T W
CL
Oven Dryer_W.M. ADDRESS16-60 " �
�� Top FAU _W.H.. _
Date��Applican�m,/`mss' CITY 0 21� Tel No.
Hood Fan —Other
NOTICE TO APPLICANT: If, after making this Certificat Disp. Room Air Cond.— LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBE Q 4y PPL Class — 10
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE SED BY_
with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR
deemed revoked.
Up to 1 Incl. FINAL
69� ®_9p p
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 Cj x
License Number •�� !� Lic.Class 0-200 Amp. Under 600 V `!J
�t 201-1000 Amp.Under 600 V
Contractor/7•/-I✓97,"-4L','S�Date �� e2 Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby 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&Conductor s
I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 21 7 9,6 A
structure is not intended or offered for sale (Section e
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY # ° 0 0 0 0 2
I hereby affirm that there is a construction lending agency 2 ° ° 51212.0
for!the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.). J
Lender's Name o- o 5 2 2 0
PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address 11,02-81
PERMIT ISSUING FEE
I certify that I have read this application and state that' the TOTAL FEE ^a
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 above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date