HomeMy Public PortalAbout10425 KEY WEST ST_Electrical__ .f�
WORKERS'COMPENSATIONDECLARATION CE-806G APPLICATION FOR ELECTRICAL PERMIT
I herebyaffirm 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,Lab. C.)
FOR APPLICANT TO FILL IN SOB
Policy No. Company New Residential Bldgs.&Pools EACH NO. FEE ADDRESS 10 wr C Fy L4-)
ly'
❑ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. '� $ — $ LOCALITY
❑ Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building•inspection CROSS ST 1, FIq Y
department. Residential Swimming Pools OWNER OR r�
FIRM NAME V'si� L
Date Applicant Outlets:.Rec.—Light— Sw. MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. >_
COMPENSATION INSURANCE d
PLAN CHECK 0
(This section need not be completed if the work involved APPLICANT U .
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First o ADDRESS
Additional Cc
Total No. O
CITY Tel No.
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP U
permit is issued, I shall not employ any person in any manner PERMITW
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT' TaN 6; -SONS
e�tt K ti
Oven _ Dryer_W.M._ ADDRESS ® Q� S 1C��v N
c� c Top FAU _W.H.. -
Date Applicant CITY �y /f h Tel No.
Hood — Fan —Other
(�N�/^��va
NOTICE TO APPLICANT: If, after making this Certificate Disp. — Room Air Cond._ LICENSE OR L`
Exemption, you should become subject to the Workers' REG. NUMBER 0L 9 Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances a DISTRICT NO. PROCE ED BY
with•comply'with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR / r
deemed revoked. 3 G -
Up to 1 Incl.
' FINAL
Over 1 to 10 Incl. DATE
"
LICENSED CONTRACTORS DECLARATION `
Over 10 to 50 Incl. �—� —$� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
BY
9 (commencing with Section 7000).of Division 3 of the Busi- Over 100
ness and Professions.Code, and my license is in full force and
effect. Services
License Number 3051 4f'y�a�. Lic.Class -l 0-200 Amp. Under 600 V J
201-1000 Amp. Under 600 V
Contractor%`9d'lni-.TIfVA' ?kQ ate Za-W-1 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): 1 .8 1,0 A
Misc.-Conduits&Conductors
❑ 1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— #"o o o o o 2
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 2 o'b 5 2 2.r,,
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency o 0 0 522 5 H
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.). 1,0 2—8 1
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address 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