HomeMy Public PortalAbout6006 OAK AVE_Electrical__ WORKERS COMPENSATION DECLARATION 76AS63
CE-806G (2 BO) APPLICATION FOR ELECTRICAL PERMIT
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I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELESy BUILDING AND SAFETY
Insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN 6/
New Residential Bldgs &Pools EACH NO FEE ADDRESS 00 O
PK .40E
0 Certified copy ahereby furnished 1&2 Family Sq Ft $ — $ LOCALITYAREST
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Certified copy is filed with the county building inspection Multifamily Sq Ft CROSS ST
department Residential Swimming Pools OWNER OR �►y `L
FIRM NAME
Date Applicant Outlets Rec_LightSw MAIL
first 20 ADDRESS X006 OA V— C1 1-7 D
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY T mnc IT Tel No Z 6--3
COMPENSATION INSURANCE PLAN CHECK
(This section need not be completed if the work urvohred APPLICANT
by the perentt is for one hundred dollars (5100) or less) Lighting Fixtures First 20 ADDRESS Q
Total No Additional
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No 0
permit is issued I shall not employ any person in any manner PERMIT 13
so as to become subject to the Workers Compensation Laws Range_Heater D W _ APPLICANT W
Oven _Dryer_W M ADDRESS O Q A K VE41,72b Z
Date Applicant Top _FAU _W H
Hood _Fan _Other_ CITY r �.1T Tel No Z f9 6 _34 It
NOTICE TO APPLICANT If after making this Certificate of Disp _Room Air Cond_ CENSE OR
Exemption you should become subject to the Workers REG NUMBER Class
Compensation provisions of the Labor Code you must forth Power Apparatus&Large Appliances DISTRICT NO PROLES ED BY
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVA .
d
deemed revoked Up to 1 Incl _
FINAL
Over 1 to 10 Incl DATE Z ���� VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
BY
9 (commencing with Section 7000)of Division 3 of the Busi Over 100
ness and Professions Code and my license is in full force and
effect Services
0.200 Amp Under 600 V
License Number Lic Class 201 1000 Amp Under 600 V
Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits a n
nese and Professions Code) 71 e * 34.7
Misc Conduits&Conductors
INI as owner of the property will do the work and the Other(See Complete Fee Schedule)— so 034755
structure is not intended or offered for sale (Section
7044 Business and Professions Code) n 07-82
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued(Sec 3097 Civ C)
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee)
Lender s Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE 34
above 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 mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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l CUt.._.n . .
996L,, 912-
Signatu of Permittee Dale