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-� ,,�bf WORKERS'COMPENSATION DECLARATION CE-806 10/e1 APPLICATION FOR ELECTRICAL PERMIT
�I he'Baby affirm that I have a certificate of consent to.self CE-806G
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof.(Sec. 3800, Lab. C.)
Policy No-551011 S Company sIMTR FEM I FOR APPLICANT TO FILL IN JOB RTr_Ff0�11D IM
copy is hereby furnished. New Residential Bldgs. &Pools
EACH NO. FEE ADDRESS 9718
_ 3 LOCALITY
Certified copy is filed with the county building inspec- 1 8 2-Family, Sq Ft. 3$19 $ n-an
F1144114,19 raw
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Date 12-1-86 Applicant JEMMs$ Rr- --:TM'1�� FIRMNER OR
NAME
QjjMnFym
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light SwMAIL
._
COMPENSATION INSURANCE ADDRESS 2035 PRIME= :?f
(This section need not be completed if the work involved.by First 20
the permit.is for one hundred dollars($100)or less.) Total No. Additional CITY Tel. No.359-3211
I certify that in the performance of the work for which this PLAN CHECK
APPLICANT
permit is issued, I.shall not employ any person in any manner i
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
- Total No. Additional -
Date Applicant-- CITY Tel, No.
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT mss$ 7 .F�'792TC 12C.Exemption, you should become subject to the Workers' Range_ Heater—D.W.
Compensation provisions of the Labor Code; you must forth- I Oven —Dryer _W.M.— ADDRESS 3876 DQ NM ]RD.
with comply with such provisions at this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY
Hood _ Fan. _Other_ B�J7sTTl1i PARK Tel.:-No-338-2558
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. — Room Air Cond. Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER —
(commencing with Section 7000)of Division 3 of the BusinesspoApparatus&Large Appliances DISTRICT NO. PROCES D Y >
Power and Professions Code,and my license is in full force and effect. �J�
Size&Type HP, KW, KVA, or KVAR- V d' (0)
License Number-- 2159475 Lia. Class r. 1)vn
Up to 1 Incl'._ —'FINAL',D
ti —
Over 1 to 10 Incl. AT
Contractor rELECERW ate �2�—$6• VAL ATION lm
❑ Over 10 to 50 Incl. W
FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY n:
B.&P.C. for this reason Over 100 6 7 A
U)
Date: Services, Swbd., MCC&Panelboards
0 -200 Amp. Under-600 V ( # 0'00002
Signature 201 - 1000 Amp: Under 600 V1o.- 7962
El
1000 Amp. or Over 600 V
'
Exemption for Reg: Maint. Elect. 0 0 0 7 9 6 2 5
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch.Circuit 1 224-86
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
Professions 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.Corriplete Fee Schedule)— ,
7044, Business and Professions Code).
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) 69.12
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 1.O .5O
Lender's Address
I certify that I haveread this application and state that the TOTAL FEE 79.62
above information is torr ct. I agree to comply with all County
ordinanc and State I s regulating Electrical wiring, and
hereby thj
re tatives.of this County to enter upon ,
t e-md operty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date