HomeMy Public PortalAbout5300-5302-5304-5306 VILLAGE CIRCLE DR_Electrical__ WORKERS' COMPENSATION DECLARATION CE-806 10/81 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 J.
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO, FEE ADDRESS',
1 & 2-Famil S Ft. $ — $ LOCALITY
Certified copy is filed with the county building inspec- y- q
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
OWNER OR
Date Applicant
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
First 20
(This section need not be completed if the work involved by Total NoAdditional CITY Tel. No.
.
the permit is for one hundred dollars ($100)or less.) 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 WorkersS CWrtpensatkoa Laws. Lighting Fixtures First 20 ADDRESS
Total No.. Additional CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
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— CITY14—..1, Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSFOR
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 NOPROCESSED BY p},•
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances O
Size & Type HP, KW, KVA, or KVAR V
License Number a Lic. ClassUp to 1 InclFINAL UJ
. DATE
Over 1 to 10 Incl. VALIDATION u_
Contractor Date l
0 I
Over 10 to 5nc.
❑ FINAL W
1 am exempt under Sec. Over 50 to 100 Inc. BY Q
Over 100
B.&P.C. for this reason O
Services, Swbd., MCC & Panelboards ► d
Date: 0 - 200 Amp. Under 600 V W
Signature 201 - 1000 Amp. Under 600 V a'
El Exemption
1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License • r '' ��
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): • a r
❑ I, as owner of the property, will do the work and the Misc. Conduits & Conductors ;1..
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , (' i -• C
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 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-meritioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date