HomeMy Public PortalAbout9828 KEY WEST ST_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 10/e1 APPLICATION FOR ELECTRICAL, PERMIT '
I hereby 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
ora certified copy thereof (Sec 3800, Lab C ) /
Policy No � Company FOR APPLICANT TO FILL IN JOB 977"' ,
J
Certified co is hereby furnished 4 EACH NO FEE ADDRESS ,
PY Y New Residential Bldgs & Pools
❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sci Ft $ — $ LOCALITY
� — T"
tion department Multi-family Scl Ft CROSSST NEARE
Residential Swimming Pools OWNER OR ISL C
„ Date Applicant FIRM NAME r dim 2
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light First 20 Sw_ MAIL !�
COMPENSATION INSURANCE ADDRESS /
'
(This section need not be completed if the work involved by Total No Additional CITY r' ��— Tel Na2� --A1`
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
o as to become subject to the Workers'Compensation Laws Lighting Fixtures First 20 ADDRESS
I No Additional _ CITY, Tel No
ate pplicant� Fixed Appliances Not Over 1 HP PERMIT -
NOTI TO PPL
ICANT If, after ma 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
with comply with such provisions or this permit shall be Top FAU W H —
deemed revoked Hood _ Fan —Other— CITY �y - Tel No Zp�.-f
49
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that jam licensed under provisions of Chapter 9 Disp — Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROC SED BY
and Professions Code,and my license is in full-force and effect Power Apparatus& Large Appliances A.
Size &Type HP, KW, KVA, or KVAR S! O
License Number Lic Class Up to 1 Incl FINAL u
Over 1 to 10 Incl DATE _4�_ VALIDATION 09
Contractor Date Over 10 to 50 Incl
FINAL U
u
/❑ I am exempt under SecOver 50 to 100 Inc BY LU
B&P C for this reason Over 100
Date Services, Swbd , MCC & Panelboords ► —
0 -200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V
Over 1000 Amp or Over 600 V
❑
Exemption for Reg MaintY Eject
SINGLE FAMILY Temp Power Pole &Appurtenances 2 8 7 8 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit -0
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits # o o'0 0 0
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Law for the following reason (Section 7031 5, Business and ,-
Professions Code) 2 0 25,50
,
❑ Misc Conduits 8 Conductors �
j, as owner of the property, will do the work and the o 0 0 2,a 5 ~
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)—
7044, Business and Professions Code) '06 1 5-83
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 O SCI
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 jaws 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
f Signat f Permittee-- DG to