HomeMy Public PortalAbout6040 ROWLAND AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 APPLICATION FOR .ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self { COUNTY OF LOS ANGELES / l . BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy.thereof(Sec.380.0,Lab.C.)
i FOR APPLICANT TO F.ILL:IN JOB
Policy No. Company New Residential Bldgs.&Pools. EACH NO. FEE ADDRESS
❑ Certified copy is-hereby furnished. 1 &2-Family,Sq. Ft. $. — $.. LOCALITY 6
ONEAREST
Certified copy is filed with the county building inspection Multi-.family Sq. Ft. CROSS ST if
department. Residential Swimming Pools .', OWNER OR
I IrIRM NAME
Date. Applicant Outlets: Rec.ULight._&Sw.__ ,Zv ADDRESS
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional O CITY Tel No:
COMPENSATION INSURANCE d
PLAN CHE91K0
(This, section need not be completed if the. work involved APPLICANT V
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20
ADDRESS VI /��r, W
Total No._6 Additional ^ O
I certify that in the performance of.the work for which this CITY (1 4 Tel No. I—
ermit is issued, I shall not employ any.person in an Fixed Appliances Not Over 1 HP G� V
p p y manner PERMIT
so as to become subject to the Wo ers'Compensation Laws. Range�Heater D.W._ APPLICANT -. CIL
sn
Q Oven .1., Dryer_W.M._ ADDRESS �- � �
Date V�Ap.plicant Top FAU �l W.H.._ —
Hood Fan'�t7ther— R
CITY Tel No.
NOTICE TO APPLICANT:If, after making this Certificate of Disp. Room Air Cond— O LICENSE O
Exemption, you should become .subject to the Workers' REG.NUMBEg Class
Compensation probisions of the Labor Code,.you must forth- Power Apparatus&Large Appliances DISTRICT NO. PROCESS D I Y
with comply withsuch provisions or this permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR � f�
Up to 1 Incl. V
FINAL
LICENSED CONTRACTORS DECLARATION I Over 1 to 10 Incl. DATE ►� .pr VALIDATION
Ovgr 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 1'00 BY
ness and Professions.Code, and my license isin full force and aJ.
effect. Services
a� 0-200 Amp.Under 600 V / � /
License Numbe tic.Class 201=1000 Amp:Under 600 V
Contracto Date��Z ^9� Over.1.40a0.Amp.or Over.600 V a ! U ](! LI
HOME OWNER-BUILDER DECLARATION Temp.Power Pole.&Appurtenances � �' o o 0 o o 2
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit _ o - 6600�
License 'Law for the following reason (Section 7031.5, Busi- Additional.Sion Branch Circuits '
ness and Professions Code):
Misc.Conduits&Conductors
Ell, as owner .of the property, will do the work and the Other(See Complete Fee Schedule)— 0624-83
structure is not intended or offered for sale (Section'
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 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
0 •
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 Smoorize representatives of this County to enter upon
the a v entioned prope f r inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
ignature of Pe it ee Date