HomeMy Public PortalAbout5931 PRIMROSE AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION
CE-806G (2-80) APPEICATIOINTIOR -EE�ECTRKAI PEf�MI:T-977
CE 806
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB
Policy No. Company EACH NO. FEE ADDRESS
❑ New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY
a Multi-family Sq. Ft. — NEAREST Q Q Cit
Certified copy is filed with the county building inspection Residential Swimming CROSS ST
Pools
Ir y
department. OWNER OR
rCL
FIRM NAME 11
Date Applicant Outlets: Reoj1,Light��Sw. ADDRESS 1 Q
�i� itiFirst 2
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.56 Additional CITY 593 7 mxa*11116. W
COMPENSATION INSURANCE PLANe
MenAPPLICAN City tl
(This section need not be completed if the work involved Lighting Fixtures 20 - a
by' the permit is for one hundred dollars ($100) or less.) FirstADDRESS
Additional
I certify that in the performance of the work for which this Total pplilNo. �_ CITY Tel No. cc
permit is issued, I shall not employ an Fixed Appliances Not Over 1 HP
p p y y person in any manner PERMIT d
so as to become subject to the Workers' Compensation Laws. Range_Heater_D.W. _ APPLICANT
Oven _ Dryer_W.M._ ADDRESS sonlee & 9-o—n-8-1-ectria W
�
Date2,�lpplicant Top _ FAU ,W.H. _ CITY ' el qbrlet
Hood _ Fan 2-Other T
NOTICE TO APPLICANT: If, after making this Certificate of Disp. Room Air Cond.— LICEN.$E„QR ; a28171-2007
Exemption, you should become subject to the Workers' REG. NUMBLR Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCES BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR
Up to 1 Incl.
Over 1 to 10 Incl FINAL
LICENSED CONTRACTORS DECLARATION DATE VALIDATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
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
License NumbeA42432 Lic.Class- C14 0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Contractn"141d1IDate 4/23/82 Over 1000 Amp.or Over 600 V
glectrix
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit n
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code): :+ w a
Misc.Conduits&Conductors
Ell, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— 0 " +. 1
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 1
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
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. SE E'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date '