HomeMy Public PortalAbout10415 KEY WEST ST_Electrical__ WORKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT �4T
I hereby affirm that I have a certificateofconsent to self COUNTY OF LOS ANGELES 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 Q / K1r1V
New Residential Bldgs &P ols
E Certified copy,is hereby furnished 1 &2-Family,Sq Ft I�/o $ — $ LOCALITY
Multi-family Sq Ft — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department Residential Swimming Pools OWNER OR
` FIRM NAME � /y bind—P.
,
Date Applicant Outlets Rec_Light_ Sw MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional CITY Tel No } r
COMPENSATION INSURANCE PLAN CHECK tl
(This section need not be completed if the work,involved APPLICANT OVo
by the permit is for one hundred dollars ($100) or'less.) Lighting Fixtures First 20 ADDRESS
Total No Additional cc
I certify that in the performance of the work for which this CITY Tel No F-
Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any person in any manner PERMIT » j' LU
so as to become subject to the Workers' Compensation Laws Range_ Heater D W APPLICANT 1(i��fv �l�/.Sceiv a.
OvenDryer_W M ADDRESS ^� - �� Z
Dateb/gni Applicant Top FAU _W H
Hood Fan _Other_ CITU® 'T g/0 Tel No
NOTICE'TO APPLICANT If, after making this Certificate o Disp Room Air Cond_ LICENSE OR .�
Exemption, you should become subject to the Workers REG NUMBER P2' Class
101,
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances _ DISTRICT NO PROC SED BY
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP,KW, KVA,or KVAR !,
Up to 1 Incl CJ
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl DATE // �?/ VALIDATION
Over 10 to 50 Incl f r O
1 hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL f
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY d
ness and Professions Code, and my license is in full force and d
effect Services / , G� •� .l
License Number�y 9�ZLic Class �� �d 0-200 Amp Under 600 V 13, G.� //OCA L"
201-1000 Amp Under 600 V
Contractor Over 1000 Amp or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp Power Pole&Appurtenances
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's Additional Sign Branch Circuits
License Law for the following reason,(Section 7031 5, Busi-
ness and Professions Code)
' Misc Conduits&Conductors '
El I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 1 8 Q 9 A'
structure is not intended or offered for sale (Section
7044, Business and Professions Code) #,o o 0 0 o 2
CONSTRUCTION LENDING AGENCY
i hereby affirm that there is a construction lending agency 1 2;o 0 52.2 5�
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) t` �C
issued (Sec 3097,Civ C ) ti 1 'f� Z 0 0 o 5 2 2 55 J
t—
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
1 1,02-81
Lender's Address PERMIT ISSUING FEE '
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 above-mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date