HomeMy Public PortalAbout5955 SULTANA AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self �•�'
insure, or a certificate.of Workers'Compensation Insurance, ! COUNTY OF LOS ANGELES _r
d BUILDING AND SAFETY
or a.certified copy thereof(Sec. 3800, Lab. C.) j
Policy No. Company
FOR APPLICANT TO FILL IN JOB ._
Certified copy is hereby furnished. New Residential Bldgs. &Pool EACH NO. FEE ADDRESS o
❑ 1 &2-Family, S Ft. $ �d.t? — $ LOCALI
Certified copy is filed With the county building inspec- y� q'
tion department. Multi-family Sq. Ft. NEARESTCROSS ST.
Date Applicant Residential Swimming Pools OWNER ORC
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Out ts: ReLightSw�Of
MAIL
COMPENSATION INSURANCE ADDRESS e
First 20 A
(This section need not be completed if the work involved by CI /� Tel. N
the permit is for one hundred dollars($100)or less.) Tota N Additional
PLAN CHECK.
I certify that in the performance of
ork for whi this APPLICANT
permit is issued, I shall not employ a p rso in any anner
so 2AEP
t to the Wo M p L s. Lighting tures First 20 ADDRESS
Total No Additional -CITY Tel. No.
Dat plican Fixed Appli ces Not Over 1 HP PERMIT
NOTI T PPLICANT: If, of m ng this' a tificate of APPLICANT Lr7+�
Exem tion, ou should become bject to the Workers' Range— eater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven _ er . W.M.. ADDRESS e
with. comply with such provisions or this permit shall be Top _ F U W.H.
deemed revoked. Hood — Fa Other— CITY Tel. IV'o. P
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. II Roo Air and. REG.NUMBER [� Class.. .—(N
I hereby affirm.that I am licensed under,provisions of Chapter 9 T
(commencing with Section 7000)of Division 3 of the Business power Apparatus 8 urge Appliances DISTRICT NO. PROCE ED BY
and Professions Code,and my license is in full force and effect.
S(lze&Type K , KVA, or KVAR ,Q O
License Number Lic. Class p to Incl. FINAL � 1 �e t.�'�
/. Over 1 10 Incl. DATE `�/ ll,I� VALIDATION @9
Contractor Date❑ Over 10' 50 Incl;
_ FINAL I am exempt under Sec. Over 50 t 100 Inc.. BYIL
�� /
BAP.C. for this reason Over 100 U)
Date: IServices, MCC&P elboards ►
0Under V
Signature- 201 -4- Amp. Under 6 V
❑ 1 Over 1000 Amp. or Over 6- V
Exemption for Reg. Maint. Elect. 1! 5 9 7 A
SINGLE FAMILY Temp. Power Pole&Appurtena es
HOME OWNER-BUILDER DECLARATION Sign with One Branch.Circuit 0 0 0 0 o G
I hereby affirm that I am exempt from the Contractor's License 'Additional Sign Branch Circuits
t Law for the following reason (Section 7031.5, Business and 2 0 o 6.&97
( Professions Code):
6 ❑ I; as owner of the property, Misc. Conduits&Conductors n o o /J .; z
0� p p ty, will do the work and the Other See Complete Fee Schedule '
structure is not intended or offered for sale Section ( p )—
7044, Business and Professions Code).
( Q 1 -83
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 PERMITFEE (Sub-Total).
(Sec. 3097,Civ. C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE rU
Lender's Address - y
I certify that I have read this application and state that the 1TOTAL FEE ,
above i r ation is correct. I agree to comply with all County
ordin ces nd State law regulating Electrical wiring, and
here a oriz repres at Yes.of this County to enter upon
the oned pe y for inspection urposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE •
S' n of:PernppDote