HomeMy Public PortalAbout5615 TEMPLE CITY BLVD_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 ID.e, APPLICATION FOR ELECTRICAL PERMIT
I hereby 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. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS
F1 Certified co is filed with the coup building ins 18 2-Family, $ Ft. $ — E LOCALITY
PY ry 9 Pec- q.
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools
CROSS ST.
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAR
Outlets: RecLight=$wi=
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work invoivod by First ti
the permit is for one hundred dollars($100)or loss.) Total No. j� Additional CITY Tal. No. -
certify that In the performance of the work for which this PLAN CHECKAPPLICANT
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 _ ADDRESS
Date Applicant Additional
Total No. /.-- CITY tel. No.
- t
NOTICE APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT
Exemption,n, you should became 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 r- -r 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 DISTRICT NO. PROCESSE -BY >
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances It.
Size 8 Type HP, KW, KVA, or KVAR 0
License Number Lic. Class Up to I Incl. FINAL - u+
Over 1 to 10 Ind. DATE LL
Contractor Date VALIDATION
OOver 10 to 50 Incl. FINAL }y,
I am exempt under Sec. Over 50 to 100 Inc. By <
B.BP.C. for this reason Over 100 Its
O
Dore: Services, Swbd., MCC 8 Ponelboards 11011, a
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑
Exemption for Reg. MainOver 1000 Amp. or Over 600 V
Mainz Elect.
SINGLE FAMILYTemp. Power Pole E Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit -
t hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Low 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 8 Conductors t
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044, Business and Professions Code). ► • • + .`: :-)( ?
CONSTRUCTION LENDING AGENCY n r
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)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address -
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. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date