HomeMy Public PortalAbout5755 RIO HONDO AVE_Electrical__ • .,.offirm that
COMPENSATION DECLAkRAT!` N CE-806 10/81 APPLICATION FOR .ELECTRICAL PERMIT
I,h�ie,reby affirm that I have a certificate of consent to ielf CE-806G
iniorbVs,1ry)Wj rtificate of Workers'Compensation Insurance., COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certifie copy thereof(Sec. 3800, Lab. C.)
Policy No." Company 'FOR APPLICANT TO FILL IN JOB
ADDRESS it J (�
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE
/ / .00
❑
$ _ LOCALITY
Certified copy is filed with the county building inspec- 1 &2-Family,Sq. Ft..
tion department. Multi-family Sq.Sq. Ft. CROSS ST. j ./� •-
Residential Swimming Pools OWNER OR '
Date Applicant FIRM NAME 4 111.14A_11-5
CERTIFICATE.OF EXEMPTION FROM WORKERS' � MAIL
Outlets: Re Light Sw!!r/
COMPENSATION INSURANCE � ADDRESS
( completed if the work Involved b
This section need not be com First 20
Y CITY'' Te
. l. o.
the permit is for one hundred dollars(5100).or less.) Total NoAdditional PLAN CHECK
I certify that in the performance of the work for which this :APPLICANT
permit is issued, I-shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 00ADDRESS
1 00
Date Applicant
Total No. Additional
CITY Tel. No.
` '
Fixed Appliances Not Over"1 HP� PERMIT 11)
•NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT-'
Exemption, you should become subject to the Workers` Range_ Heater_D.W. —
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. Hood _ Fan _Other_ CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG.NUMBER Class.
(commencing with Section 7000) of Division 3.of the Business Power Apparatus&Large Appliances DISTRICT NO, PROCESS D BY =,
and Professions Code,and my license is'in full force and effect. 5 9L
Size; &Ty pg HP, KW, KVA, or KVAR; – V a
License Number Lic. Class (•�° �h Up to 1 Incl. ��. / FINAL
Over 1 to 10 Incl. DATE VALIDATION ad
Contractor Date _ Over 10 to 50 Incl.,
FINAL
I am exempt under Sec. Over 50 to 100_Inc. BY
B.&P.C. for this reason _ Over 100 Z&JV)
Date: S MCC&Panelboards
0 -2 p. Under 600 V v
Signature 27 000 Amp. Under 600 V 21560 p
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. # 0 0 0 0 02
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit i - . 9a50
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits ''t o 0 0 9 5 0
Law for the following reason (Section 7031.5, Business and
Professions Code): � 0221 -85
� I,1, as owner of the property, will do the work and the !sc. Conduits&Conductors
O 1ilucture is not intended or offered for sale (Section Other(See Comp ete Fee Schedule)_
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction'lending agency for
the perf6rmance of the work for which this permit is issued PER T FEE (Sub-Total) i
(Sec. 3097, Civ. C.).
PLAN-CHECKING FEE
Lender's Name
PERMIT ISSUING.FEE o
Lender's Address
I certify that I have read this application and state that the I TOTAL FEE s
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-mentiond_property for inspection purposes. ✓ SEE REVERSE FOR EXPLANATORY LANGUAGE i
�ntur, rmittee Date