HomeMy Public PortalAbout10155 LOWER AZUSA RD_Electrical__ 4UQRKERS' COMPENSATION DECLARATION 76- 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT
I Wh Teby affirm;that I have'2 certificate of consent to self insure,
CE-806G
or �i certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab. C.) <�/�_ _
POI'C No. X91&3 Company r 4 � t FEND FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnishedAcoub
New Residential Bldgs.& Poo
EACH NO. FEE ADDRESS q e5
Certified copy is filed with the4,ip�ection
1 & 2-Family,Sq.Ft. Z� $ 1U` — $ p , LOCALITY
department. Multi-family Sq.Ft. NEAREST / ,y
CROSS ST.
Residential Swimming Pools OWNER OR
Date j Applicant , FIRM NAME '
CERTIF ATE OF EXEMPTION F O O ERS' Outlets:Rec—Light Sw. — MAIL
COMPENSATION INSURANCE ADDRESS oZ
(This section need not be completed if the work involved by the First 20 2
permit is for one hundred dollars($100)or less.)
Total No. Additional CITY OJ el.No'
I certify that in the performance of the work for which this permit APPLICANT CHECKPLAN
is.issued, I shall not employ any person in.any manner so as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT t
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top — FAU _ W.H.
CITY Tel.Noa
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR
(commencing with Section 7000) of.Division 3 of the Business and REG.NUMBS Class. !�Oj
Professions Code,and my'license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. J PROCE SED BY
J/ ,
JT7 CJ `® Size&Type HP,KW,KVA,or KVAR 1 U
License Number Lic.Class Up to 1 Incl FINAL _
04
Over 1 to 10 Incl. DATE -���'�� LIDATIONQ
Contractor LiT1 /t/�iS "r•'�y+�LDate
Over 10 to 50 Incl. FI 17—
0
I am exempt under Sec. Over 50 to 100 Inc. g d
B.&P.C.for this reason Over 100 N
Services,Swbd.,MCC& Panelboards Z
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
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 Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
ElI,as owner of the property,will do the work and the structure Misc.Conduits& Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) .
and Professions Code).
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(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.). .,
PLAN CHECKING FEE
Lender's Name Z► MW
PERMIT ISSUING FEE C C� a.:� - �
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and State la regulating Electrical wiring, and hereby authorize
representativ of t Cou y t0 enter upon the above-mentioned
property for pe i pur ses. '"•
SEE REVERSE FOR EXPLANATORY LANGUAGE it 1 '1
u
Sign V`7
e to -r- ..0 1--.1 r-0 d