HomeMy Public PortalAbout6356 OAK AVE_Electrical__ WORKER S'COMPENSATION DECLARATION APPLICATION FOR ELECTRICAL PERMIT -
:, ��•. CE-806G (2.801
I hereby affirm that I have a certificate of'consent to self COUNTY OF LOS ANGELES may— G BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or /
a ff��,r,tified copy thereof Sec.380.9,—Lab.C
YciIGS/(f FOR APPLICANT TO FILL IN JOB
Policy No. Company /
New Residential Bldgs.&,P,o�o`lJl� EACH NO. FEE ADDRESS
Certified copy is hereby furnished. 1 &2-Family.Sq.Ft.�M*0 $ le.3 — $ - IY LOCALITYoto
Ft. — NEAREST �-.
Certified copy is filed with the•county.liuilding inspection Multi-family Sq. CROSS.ST
depart ant. Residential Swimming Pools OWNER OR
.� FIRM NAME
DateApplicant • Outlets: Rec Light�•Sw. ! MAIL r
First 20 ]ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Addit'i al Cl Tel No. S }� '
COMPENSATION INSURANCE PLA 'CH K
APPLICANT
(This ,section need not be completed if the work involved Lighting Fixture rst 20
by the permit is for one hundred dollars .($100) or less.). ADDR'E6S W
Total No. Additional O
I certify that in the performance of the work Poi which this. CITY I ' Tel No. (—
permit is issued, I shall not employ any person in any manner Fixed Appliances N Over 1 HP'
i,
PERMIT, W
so as to become subject to the Workers'Compensation Laws. Range He er D.W. APPLICANT GI IL
Oven' er M. ADDRESS £' W
Date Applicant Top FAU _W.H. `
Hood Fan _ •.ther_ CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond— LICENSE OR �,/� /
Exemption, you should become subject to the Workers' REG.NUMBER `-64 Class0-;10
Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances DISTRICT NO. PROC SED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR Q� t
Up to 1 Incl..
, gL _ry
LICENSED CONTRACTORS DEC Over 1 to 10 Incl. DATE
LARATION ' VALIDATION
Over 10 to 50 Incl. ��
I hereby affirm that,I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL f�
9 (commencing with Section 7000)of Division.3 of the.Busi- Over 100• BY '
ness and Professions,Code,:and my license is in full force and ,
effect. Services ' .e�
License Number Lic.Class 0-200.Amp.Under 600 V / y�7
�` 201-1000 Amp.Under 600 V
Contract o Date k '`0 z- Ovei 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt•from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi= Additional.Sign Branch Circuits
ness and Professions Code):
-2430,5A
Misc.-Conduits&Conductors "
E3 I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— 1' 0 0 oI o o
structure is not intended or-offered for sale (Section
7044,Business and Professions Code). o...- 3970
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction:lending agency I o 0 0 3 9,7 C v'
for 'the performance of the work for which'this permit is
issued(Sec.3097,Civ. PERMIT FEE (Sub-Total) @ 0608,-82
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
T certify that,I have read this application and state. that the TOTAL FEE 7dI
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
Z
ve-mention pro arty for inspection pur oses ' SEE•REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitte Date