HomeMy Public PortalAbout5568 WELLAND AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE-806 10/81 ���L�ICATI®IN F®R ��� �RICAL PERMIT �� 8��� 7
I heceby 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� GG/'thereof .1 3800, LL*i"
Policy No. W ke- Company FOR APPLICANT TO FILL IN
}b�j1 JOB p-y r��
Certified.copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS ]i7 W�
❑ 1 &2-Family, S Ft. $ _Is LOCALITY i!f l
Certified copy is filed with the Dunt building inspec- y q NEAREST
tion epartment. Multi-family Sq. Ft. CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR ,r C
FIRM NAME /�L' /���C�C
CERTIFICATE OF EXEMPTION ROM WORKERS' -MAIL
Outlets: Rec Light Sw— , ADDRESS SG �., '(4
COMPENSATION INSURANCE .�
First•20,,
(This section need not be completed if the work involved by Total No. Additional CITYRt Tel. No. 3-� o '
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 Workers'Compensation 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 Range_ Heater_D.W. — APPLICANT F .1�`<-Z— CRry
Exemption, you should become subject to the Workers'
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. — CITY Tel. IVo. rj��3 3
deemed revoked. Hood _ Fan _Other—
LICENSED CONTRACTORS DECLARATION REG. EOR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG.NUMBER Class ���a
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCE Y
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances VC, L
t� Size&Type HP, KW, KVA, or KVAR- ta� 00
License Number 7 7, l� Lic. Classes FINAL
—,--r— Up to 1 Incl.
1119
Over 1 to 10 Incl. DA ZVAL ATION
Contractor Date Over 10 to 50 Incl. FIN
❑ I am exempt under Sec. Over 50 to 100 Inc. BY - rU
Over 100
B.&P.C. for this reason
Services, Swbd., MCC&Panelboards
Date: .0 -200 Amp. Under 600 V 00 ;2 719.6 A
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V #.o.0 0 0 0 2
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances I o - 7(194
HOME OWNER-BUILDER DECLARATION5
Sign with One Branch Circuit o 0 0 '7 a 9 4
I hereby affirm that I am exempt from.the Contractor's License Additional Sign�Branch Circuits
Law for the following reason (Section 7031.5, Business and �j $j-$7
Professions Code):
❑ I, as owner of the property, will do the work and the M.sc. Conduits&Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agdncy 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
abo r -mentioned property for inspectio urpo es. SEE REVERSE FOR EXPLANATORY LANGUAGE
S nature of Permittee Date