HomeMy Public PortalAbout10157 LOWER AZUSA RD_Electrical__ WQRKERS' COMPENSATION DECLARATION 78to/st
CE-806G APPLICATION FOR ELECTRICAL PERMIT
d hereby affirl',that I have'a certificate of consent to self insure, os
or-.a certificate'of Workers' Compensation Insurance, or a'certified COUNTY'OF LOS'ANGELES BUILDING AND SAFETY
copy thereof((JSfflecc...33800 Lab.C.)
Policy vim"' 7� CompanyFOR APPLICANT TO FILL IN. JOB
ADDRESS �ly�
Certified copy is hereby furnished. New Residential Bldgs. & Po Is EACH NO. FEE
Certified co1 & 2-Family, Sq.Ft. $ — $ LOCALITY
copy is filed with theJCou 'ng ectio
department. Multi-family Sq.Ft. NEAREST
CROSS ST. �{„
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CER FICATE OF EXEMPTION M4WO ERS' MAIL
COMPENSATION INSURANCE Outlets:Rec— Light t 2 —
ADDRESS
(This section need not be comp o`GO[
leted if the work involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional. CITY ��o I.No.
PLAN CHECK
I Certify that in the performance.of the work for which this permit APPLICANT
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.
DateApplicant Fixed Appliances Not Over 1 HIP PERMIT
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.
LICENSED CONTRACTORS DECLARATIONCITY Tel.No.
Hood — Fan Other—
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. Room Air Cond. REG.NUMBER Class.
(commencing'with Section 7000) of'Division 3 of the Business and
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. �f PROCESSEWEY
p aSize& Type HP,KW,KVA,or KVAR
V
License Number Lic.Class /12 Up to 1 Incl FINAL U
Contractor -SY ZeDate caZ Over 1 to 10 Incl. DATE �� O
V I ATION
Over 10 to 50 Incl. U
am exempt under Sec. 77
Over 50 to 100 Inc. FINAL BY W
B.&P.C+for this reason Over 100 N
Services,Swbd.,MCC& Panelboards Z
Date: 0- 200 Amp.Under 600 V 11M "
Signature 201 - 1000 Amp.Under 600 V a
❑ 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):
❑ Misc.Conduits & Conductors
I,as owner of the property,will do the work and the structure
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.). C: t: f`. w
I C:! �y F. y?.
PLAN CHECKING FEE fs t;; x_r T: Erol +.,-;
Lender's Name
PERMIT ISSUING FEE I-smi
Lender's Address ' f
I certify that I have read thisapplication and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
represMi'sp
s C unty to enter upon the above-mentioned
properon rposes. 4: `
' SEE REVERSE,FOR EXPLANATORY LANGUAGECO
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