HomeMy Public PortalAbout5729 TEMPLE CITY BLVD_Electrical__ RKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
! �* CE-806
I hereby affirm that I have a certificate of consent to self, COUNTY OF LOS ANGELES BUILDING AND SAFETY
Insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO.FILL IN JOB _.7A
New Residential Bldgs.&Pools EACH NO. FEE ' ADDRESS —�
Certified copy is hereby furnished. ` 1 &2-Family.Sq. Ft. $ — $ LOCALITY
❑ Multi-family Sq.Ft. EAREST JF
Certified copy is filed with the county building inspection Residential Swimming.Pools CROSS ST
department. OWNER OR
FIRM NAME
Date Applicant Outlets: Rec.—Light Sw. MAIL //��♦♦
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional. CIT �r Tel No �7. >:COMPENSATION.INSUMANCE
PLAN CHECD-
APPLICANTK' Y 0
(This section need not be completed if the work involved Lighting Fixtures First 20 0
by the permit is for one hundred. dollars ($100) or less.) ADDRE
Tdtal No.— Additional
I certify that in the performance of the work for which this Fiiced Appliances Not Over 1 HP CITY Te o.
permit is issued,I shall not employ any person in any manner PER
MIS
so as to become subject to the Workers'Com ensation Laws. Range—Heater D.W._ APPLICAN �`Y�K d y
Oven _ Dryer_W.M. ADDRESS ` .6. S.
Date Applicant Top- _ FAU _W.H.._ _ m,
Hood — Fan _Other_ CITY Tel No
NOTICE T APPLICANT: If, after making this Artifica.te of Disp. _Room Air Condom LICENSE OR -7 ..L
Exemption, you. should become subject to the Workers' i REG.NUMBER • / lass 1r
Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large Appliances DISTRICT O. PRO SSE.D BY
with comply with such provisions or this. permit shall be J�/
deemed revoked. Size&Type HP,KW,KVA,or KVAR � /
Up to 1 Incl. '.
Over 1 to 10 Incl. DATE
-FINAL �
LICENSED CONTRACTORS DECLARATION � VALI DATI
Qver 10 to 50 Inc[.
FINAL
I hereby affirm that I-am licensed,under provisions of Chapter Over 50 to 100 Inc.
BY
9 (commencing with Section 7000)of Division 3-of the Busi- Over00
'1
ness and Professions.Code:,and my license is in full force and,
effect. Services
0-200 Amp.Under 600 V
License Number 5-71 r Lic.Class
_ p� VO4&ate
201-1000 Amp.Under 600 V
Contractor�r'°'I � :Y04&ate -//r +%j1 o Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION' Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit ;
License Law for the following reason (Section 7031.5,'Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits&Conductors
❑ I, as owner of the property,.will do the work and the Other(See Complete Fee Schedule)—
structure is not intended or offered for sale (Section 21 n,6
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY #;( o b o o a•2
'I hereby affirm that there is a construction lending agency
for the performance of the work for which, this permit is PERMIT FEE2 0 0 1 7.0
issued(Sec.3097,Civ.C.). (Sub-Total)
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 0 0 0
Lender's Address PERMIT ISSUING FEE
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
hereb authorize representatives of this County to enter upon
the -mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
IIV"e
Signature-of Permittee Date