HomeMy Public PortalAbout10420 MILOANN ST_Electrical__ WORKERS'COMPENSATION DEELARATION CE-806 ,U,B, APPOCATION FOR ELECTRICAL PERMIT
I hereby,affirm that I have a certificate of consent to self, CEt106G �j
insure;-6r a certificate of Workers'Compensation Insurance,I COUNTY OF LOS ANGELES BUILDING AND SAFETY IuI
or a certified copy thereof(Sec. 3800, Lab. C.) i
Policy No. Company FOR APPLICANT TO FILL IN JOB ��'�+
Certified co is.hereb furnished. EACH : NO.. FEE. 'ADDRESS �!
copy y New Residential.Bldgs. &Pools
md
Certified copy is filed with the county building lnspec- 1 &2-Family, Sq. Ft. $ — $ -L,OCALITY 7h-W,0Z,6-NEAREST Gf7
tion department. t Multi-family Sq. Ff. CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ :'MAIL
COMPENSATION INSURANCE ADDRESS
First 20
'(This section need not be-completed if,the work involved by Total No. Additional [CITY TCL G Tel. No.
-the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this I PLAN CHECK
permit is issued, I shall not employ,an person in any manner►
APPLICANT
to
as to become subject to the W rk tion Laws. Lighting Fixtures First 20 ADDRESS
r Additional
Total No:
Date ` �'� pplicam CITY Tel. No.
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption, you should become subject .to the Workers' Range_ Heater_D.W. _
stdc '45
Compensation,provisions of the Labor:Code,, you must forth= Oven _Dryer _W.M. ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H:—
deemed-revoked. CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
Dis _ Room Air Cond. LICENSE OR
1 hereby affirm that I am licensed under provisions of Chapter 9 p' REG.NUMBER Class.
(commencing'with Section 7000) of Division 3 of the Business DISTRICT NO. PROLE Y 0-
and Professions Code,and,my license is in full force and effect. Power Apparatus.&.Large Appliances V
Size&Type HP, KW, KVA, or KVAR'
License Number Lic..ClassG=
Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE �Z VAL DATION
Contractor Date Over 10 to 50❑ Incl. till
V 5 0 FINAL a
I am exempt under Sec. Over to 100 Irrr. BY
B.&P.C. for this reason Over 100
Date: Services, Swbd., MCC&Ponelboards I ,
0 -200 Amp. Under 600 V
F-1 Signature 201 -11000 Amp. Under 0 V
Over 1000 Amp. or Overr 600 V ,
Exemption for Reg. Maint. Elect.
0 3
SINGLE FAMILY .0 0 ? 25505
Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION, Sign with One Branch Circuit1206-$5
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Prof ssions Code):
I, as owner of the property, will do.the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See.Complete Fee Schedule)_
7044, Business and Professions Code). lop
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 PERMIT FEE.' (Sub-Total)
' (Sec. 3097, Civ. C.). I
PLAN CHECKING FEE I r
Lender's Name
I PERMIT ISSUING FEE I JoIn
Lender's Address
I certify that I have read this application and state that the I'TOTAL FEE
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and f r
hereby authorize representdtives of this County to enter upon
t ned property f' r inspection purposes. ( •`
,0� SEE REVERSE FOR EXPLANATORY LANGUAGE ,
( O j
Signature of Permitteel5ate