HomeMy Public PortalAbout9627 WOOLLEY ST_Electrical__ WORKEIIS'COMPENSATIONDECLARATION CE-806 APPLICATION FOR ELECTRICAL PERMIT
CE-806G (2-80)
I hereby affirm that I have a certificate of consent to self S BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or ""�1�' '
a certified copy thereof(Sec.3800,Lab.C.)
Policy No. CompanyFOR APPLICANT TO FILL IN JOB
ADDRESS
�� New Residential Bldgs.&Pools EACH NO. FEE
ED Certified copy is hereby.£uants"" hed. 1 &2-Family,Sq. Ft. $ — $ LOCALITY
❑ Multi-family Sq. Ft. — NEAREST
Certified co . filed with the county building inspection CROSS ST
depart Residential Swimming Pools OWNER OR
FIRM NAME
Date, Applicant Outlets: Rec._LightSw. MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CfTY Tel No. d
COMPENSATION INSURANCE
PLAN H CK CL
(This section need not be completed if the work involved APPLICANT VLighting Fixtures First 20 ADDRESS
by the permit is for one hundred dollars ($100) or less.) Total Fi Additional 0
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. V
permit is issued, I shall not employ any person in any manner PERMIT
so as to become subject.to the Workers' Compensation Laws. Range_HeaterD.W. _ APPLICANT IL
N
//y� Oven _ Dryer_W.M._ ADDRESS'` �
Dat Applicant -�'i^-d Top _ FAU _W.H. _ CITY Tel No, c$�'
Hood _ Fan —Other
NO _ E T APPLICANT: If, after making this Certificate of Disp. —Room Air Cond LICENSE OR
Exe ption, you should become subject to the Workers' REG.NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSMEE BY
with comply with such provisions or this permit shall bb ®�
deemed revoked. Size&Type HP,KW,KVA,or KVAR
Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. � VAL ATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINALBY / r G
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100
ness and Professions Code, and my license is in full force and
effect. Services
License Numbe_& � Lic.Class C=Z 47 0-200 Amp.Under 600 V
S �
201-1000 Amp.Under 600 V
Contra DaeLARATION
Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER Temp.Power Pole&Appurtenances 71 9.1 A
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit # 0 0 0 0 0 2
License Law for the following reason (Section 7031.5, Busi-,. Additional Sign Branch Circuits
ness and Professions Code): f .- I ,- o29,00
,�..--'• Misc.Conduits&Conductors '
I, as owner of the property, will e work and the Other(See Complete Fee Schedule)— 29.005
structure is not intended or o fered for sale (Section
7044, Business and Professio ode).
CONSTRUCTIONZIE DING AGENCY 0608-87
I hereby affirm that therd'is a construction lending agency
for the performance .6f the work for which this permit is PERMIT FEE (Sub-Total) $ �j
issued(Sec.3097,Civ.C.).
Lender's Name X PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE Q
I certlfq that I have read this application and state that the TOTAL FEE :
above'information is correct.I agree to comply with all County Li1
ordinances and State laws regulating Electrical wiring, and
jatereby authorize re resentatives of this County to enter upon
r
v -menti d prop ty for inspection purposes. SEE•REVERSE FOR EXPLANATORY LANGUAGE
4�C=V� I
Signature of Permittee DaRe
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