HomeMy Public PortalAbout10163 LOWER AZUSA RD_Electrical__ WORKERS'COMPENSATIONDECLARATION -663 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT
F hereby affirm that I have a certificate of consent to self insure, CE
or a certificate of Workers' Compensation Insurance, or a'certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof Sec.3800,Lab.C.) A /,�/�/�n
POIi No. ✓.Company sr^'� 1 �+� FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pool EACH NO..1 FEE
❑ 1 & 2-Family, Sq. Ft $ — !_-:71"
LOCALITY
Certified copy is filed with,the county Idl s ction
department. Multi-family Sq.Ft. — NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR,
_ FIRM NAME ,
CERTIFI ATE OF•EXEMPTION FRO WOR RS' Outlets Rec— Light _ Sw. MAIL
COMPENSATION INSURANCE. > ADDRESS
(This section need not be completed if,the work involved by the First 20 CITY T41 No.
permit is for one hundred dollars($100)or less.) Total No. Additional
I certifythat in the per of the work for which this permit PLAN CHECK
P 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.
Date Applicant Fixed Appliances Not Over 1 HPPERMIT
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 DECLARATION Hood — Fan —. CITY Tel.No.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.G-a�
Professions Code,and my license is in'full force and effect. Power Apparatus&Large Appliances DISTRICT NO. _ �I PROCESSED BY
D Size & Type HP,KW,KVA,or KVAR l/ 0
License Number Lic.Class Up to 1 Incl. FI NAL
U
S SM��/'IGF,D � Over,11 to 10 Incl DATE °'��� V IDATION
Contractor ate P Over 10 to 50 Incl. U
FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
BAP.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 r>•r•- x
Code): _I
Misc.Conduits& Conductors - j
❑ . 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) _ ® i ITEMS
and Professions Code). A I
s.
2.7 .30
CONSTRUCTION LENDING AGENCY
IJ
1 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.). t i114'3- °'==1
PLAN CHECKING FEE
Lender's Name �u
PERMIT ISSUING FEE V i11j`s; —I f►.i J j, t
Lender's Address_ AM
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 -
AStatlawsgulat', g Electrical wiring, and hereby authorize
this ounty to enter upon the above mentioned
tio purposes.
SEE REVERSE FOR.EXPLANATORY LANGUAGE
tee a e