HomeMy Public PortalAbout5638 MCCULLOCH AVE_Electrical__ WORKERS'COMPENSAYION'f)ECLARATION CE-806 ,DAB, APPLICATION FOR ELECTRICAL PERMIT
I herebyiaffirm That I:hav&'a certificate of consent to self insure,
CE-806G f
'•-or a I%rtificate of Workers' Compensatlqn Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.>r.) � r9��C���
Policy No. Company / FOR APPLICANT TO FILL IN JOB 4S�
EACH NO. FEE ADDRESS
❑ Certified copy is hereby furnished.. New Residential Bldgs.&P�oolols
Certified copy is fil..ed with the county building Inspection 1 A.2-Family,Sq.Ft.1 S'4 L $ — $ LOCALITY
epartmNEARESTent. Multi-family Sq.Ft. .CROSS ST.
Date �^' Applicant Residential Swimming Pools ` OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM W KERS' Outlets:Rec—Light_Sw.— AMAIL
DDRESS ,
COMPENSATION INSURANCE
(This section need.not be completed if the work involved by the. , ' First 20
permit Is for one hundred dollars($100).or less.) Total.No.. . Additional CITY Tel.No.
I certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall.not employ any person in any manner so as to APPLICANT
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional 1 CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT /e
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 j4p h,1M, Tel No. rI
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE B Class.G10
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER O 7 ,3
Professions Code,and my license Is in full force and effect. DISTRICT NO. PR
Power Apparatus&Large Appliances
HP,
License Numberl.
�� Lic.Class .�/d Size&Type Up to W,I cVA,or KVAk FINAL
Over 1 to 10 Incl. DAT/ 2 �� VALIDATION
Contractor Date Over 10 to 50 Inc[.
FIN
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
BAP.C.for this reason Over 100 N'
Services,Swbd.,MCC&Panelboards ® R
ate: 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 Additional Sign Branch Circuits
for the following reason(Section 7031.5,Business and Professions
Code):
Misc.Conduits&Conductors
n
I, owner of the property,will do the work and the structure Other(See Complete Fee Schedule)
is not-intended or offered for sale (Section 7044, Business pop.
2737.5
and Professions Code). #,0 0 0 0 0
CONSTRUCTION LENDING AGENCY 7234
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.309.7, PERMIT FEE (Sub-Total) 8 3 2-6
Civ.C,).
PLAN CHECKING.FEE.
Lender's Name `
PERMIT ISSUING FEE (�
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 laws regulating Electrical wiring, and hereby authorize
representatives of this.County to.enter upon the above-mentioried
prop ty for inspection p1lirposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
,
Bignaturefolf Permittee Date