HomeMy Public PortalAbout8854 LONGDEN AVE_Electrical__ WORKERS'tI have a cerci DECLARATION CE-806 10,8, APPUC AMN FOR ELEC�`�MICAd PERM57
sl 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
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB �^
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS G
❑ 1 8 2-Family, S Ft, $ — $ LOCALITY
Certified copy is filed with the county building inspec- y, q•
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Date Applicant OWNER,OR dN
_ FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light7—Sw.� AIL
COMPENSATION INSURANCE ZI ADDRESS
(This section need not be completed if the work involved by First 20
the permit is for one hundred dollars ($100)or less.)
Total No /
Additional CITY T No.���cS�/`
I certify that in the performance of the work for which this PLAN CHECK
permit is.issued, I shall not employ any person in any manner APPLICANT
so as to become subject to the Work e s'Compensation Laws. Lighting Fixtures First 20 ADDRESS /
/j Total No. 2_ Additional
Date •� ..�7�b//Applicant CITY Te
NOTICE TO APPLICANT: If, after making his Certificate of Fixed Appliances Not Over 1 HP PERMIT
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 Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
II hereby affirm that I am 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��— PROCE E Y d
and Professions Code, and my license is in full force and effect. Power Apparatus 8 Large Appliances i� O
Size & Type HP, KW, KVA, or KVAR' 'L �+ V
License Number Lic. Class Up to 1 Incl. FINAL �� �� EY
Contractor Date Over 1 to 10 Incl. DATE VALIDATION E-.
F-1Over 10 to 50 Incl. FIN LLI)
I am exempt under Sec. Over 50 to 100 Inc. B a
B.&P.C. for this reason Over 100 / Z
– ��06 Services, Swbd., MCC& Panelboards D
Date: 0 - 200 Amp. Under 600 V
Signature �� �'a�'
11801 - 1000 Amp. Under 600 V
❑ Q Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
f
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
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
Professions Code): 4,71,0 A
❑ I, as owner of the property, will do the work and the Misc. Conduits& Conductors
fete Fee Schedule.Comee
S
structure is not intended or offered for sale (Section Other ( P• )— � - �#:- ..9;?-o•o;o2
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY .° 3 4 5 0 .
I hereby affirm that there is a construction lending agency for ;o o�?3 Q.5 05
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). 45 2 7'a 8 6
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
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
t a ave-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of rmittee Date