HomeMy Public PortalAbout10167 LOWER AZUSA RD_Electrical__ s . JVORKERS'.COMPENSATION DECLARATION -8 10/$1
CE-806G APPLICATION FOR ELECTRICAL PERMIT
I'hereby aff&m that I have a certificate of consent to self insure, o6
or a certificate-of that.,
Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereoff(§ec.3800,Lab. C.
�i��1 s�
Policy No.e � Company �l%/S'T FOR APPLICANT TO_FILL.IN ..JOB
EACH NO. FEE ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.& Pools / �/ 3r
❑ 1 & 2-Family,Sq.Ft. kJ,L $.,/�` _ $. I F LOCALITY
Certified copy is filed with the. cc y buil ing spection
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Date Applicant •Residential Swimming Pools OWNER OR
FIRM NAME
CERTI CATE OF EXEMPTION ERS' Outlets:Rec— Light Sw. — MAIL
COMPENSATION INS ANCE ADDRESS
This section need not be completed if the rk involved by the W.
First 20•
( p � CITY
permit is for one hundred dollars ($100)or less.) Total No. 'Additional
I,certify that in the performance,of the,work for which this permit -PLAN APPLICANT 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
NOTICE TO APPLICANT: If, after making this Certificate .of PERMIT
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.
Tel.N
omITY7m
LICENSED CONTRACTORS DECLARATION /-ZiHood _ Fan Other_
I hereby affirm that I am licensed under provisions of Chapter 9LICEN E OR
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond.. REG.NUMBS Class. I
Professions Code,and my license is in full.force and effect �DISTRICT No. PROCESS BY
Power Apparatus& Large Appliances
n Size& Type HP,'KW,KVA,or KVAR
License Number S Lic.Class c�--fG Up to 1 Incl FINAL U
Over 1 to 10 Incl. DATE �
bp�w�r LIDATION
Contracto�a7" �SV� ate l y Over 10 to 50 Incl. FIN- / V
❑ I am exempt under Sea Over 50 to 100 Inc. BY W
BAP.C. for this reason Over 100
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 Circuitsf - .a•
XDi•� e•a
Code): _ � �,
❑ q't'y
Misc.Conduits & Conductors .?+�L�� �'=��'�'
1,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) EM
and Professions Code). I T t. -9 f
4
T011AL x31'2 3
CONSTRUCTION LENDING AGENCY 281
I hereby. affirm that there is a construction lending,agency for the C�K "�
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.). CHANGE l�!
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE �� C-000"t�(�It 1/2-7/39
Lender's Address w t1 B` ='
I certify that I have read this application and state that the above TOTAL FEE 13 { 1 i-lM a.0 t �
information is correct. I agree to comply with all County ordinances
and St e laws regulating Electrical wiring, and hereby authorize
repres n tive of is C my to e er upon the above-mentioned
Pr
y or in e on p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE,
r
Si at e at