HomeMy Public PortalAbout10161 LOWER AZUSA RD_Electrical__ WORKERS'COMPENSATION DECLARATION -663 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT
I hereb>s affirm that I have a certificate of consent to self insure, CE
or a•ce'rtific'ate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab. C.)
Policy No.� Company,'�J/ 1 6 / w/VD_ FOR APPLICANT TO FILL IN - ,JOB ..
Certified co is hereby furnished. ADDRESS 0 6
copy Y New Residential Bldgs.& Pools EACH NO. FEE 7 r,
Certified copy is filed with the c my bui ing spection
1 & 2-Family, Sq. Ft. ) $ — $ J LOCALITY
department. Multi-family Sq. Ft. NEAREST y
CROSS ST. t A
Date I Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CER FICATE OF EXEMPTIO OM WO ERS' MAIL
COMPENSATION INSURANCE Outlets:Rec Light Sw.
ADDRES
This section need not be completed if the work involved b the First 20
( p y Total NoAdditional CITY � �& Tel.No. �Z
permit is for one hundred .dollars($100)or less.) ,
I certify that in the performance of the work for which this permit PLAN PLANCHET CHECK
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
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject.to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
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.No
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.NUMBER Class. C�
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROCESSED @Y
•— �.Size & Type HP,KW,KVA,or KVAR (/
License Number 3 Lic.Class Up to 1 Incl. FINAL V
r 2 Over 1 to'10 Incl. DATE VAL ATION Q
Contracto14" ate Over 10 to 50 Incl. 1 U
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY W
Over 100 4'
B.&P.C.for this reason Z
Services, Swbd.,MCC& Panelboards
Dater 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):
I,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 (Sb-Total),,,a ,
Civ.C.). �,.
PLAN CHECKING FEE x' f+i t '
Lender's Name
PERMIT ISSUING FEE
Lender's Address e • 1
I certify that I have read this application and state that the above TOTAL FEE
information is cor ect. I agree to comply with all County ordinances
and State laws u1 ng lectrical wiring, and hereby authorize
representative o i ou y to enter upon the above-mentioned _ f *• '+f
property for i pet n ur ses. SCQ
EE REVERSE FOR EXPLANATOBY.X'ANGUAGE':.j 0
' ..:. n
Signatu a• r e ate t•J