HomeMy WebLinkAbout0776A (4) w°R"ERS'`°"`P��S"T'°NDE`L`'KAT'°�, '6A663 APPUCATION F4R ELECTRICAL PERMIT �
-CE-806G(2-80) �
I hereby affirm that I have a certificate nt'consent to sels ` COUNTY OF LOS ANGELES BUILDING AND SAPETY
insure,or a certificate ot Warkers'Compensation Insurance,or �
a certified copy Ibereof(5ec.3800,Lab.C J
FOR APPUCANT TO FILL IN �pg / ���(�� ���.
-I PoliCy No. Company �-- EACH NO. FEE � �� � �
New Residential Bldc�s.&Pools AOORESS
� Cerlified copy is hereby furnished. 'I&2-Family,5q.Ft. $ — $ LOCALITV � �,.�, .��. h,
� Certified copy is filed with the county buiidin Multi-family Sq.Ft. — NEAREST �� -�- �--
g inspec2inn Residential 5wimmina Po `�j/'i � CROSS ST
departmen[. �-+ — r� OWNER OR
- �.— FIRM NAME —
Date Applican( � Outlets:Rec.�Light_Sw._ MAIL � l
- Firsr 20 ADDR 5 �`G'{�i�- C"'
� CliRTII'ICATE OF EXEMPTION FROM WORKERS' Total No. Addltiona� CITY Tel N ��
(:UMPEIvSA7'ION INSL'RANC� � "-' '< . �
PLA ECK a
APPLICANT
(This section need not be completed if the wozk involved - �
by the peimit is for one hundred dollars (S1QOJ or IessJ Lighting Fixtures First 20 --� qDDRESS �' � V
� Total No. Additional � _
I certify that in the performance of the work for ivhich this Ci7v Tel N .. ��y�-�C7 �
ermit is issued,I shall not em lo any Fixed Appliances Not Over 1 HP V
p p y person in a y manner PE R ' ~
so as[o become subject to the Wurkers'Compe ion Laws. Range_Heater_D.W. APPLICANT � �,_ W
� Oven _Dryer_W.M._ ADDRESS �
t ��,,,/�, Top _FAU _W.H._ Z
D$tc����'/�YJ._).,_fAPPlicant ' —
�t Hood _Fan _Other_ CITY Te1No.
NOTI F'I'O AYPLICANT: ,after m� ing this Certificaie of �Disp. _Room Air Cond._ LICENSE OR y
Exemption, you shnuid become subject to [he Workers' REG.NUMBER �/ � Ciass
�C.ompensetion provisions of the Labor Code,you must forth- power Apparetus&Large Appiiances �ISTFiICT No. PRoCESS �BV
with comply with such provisions or Chis permit shall be "
deemed revoked. . Size&Type HP„KW,KVA,or KVAR l�/ ?
. Up to t Incl. _ - "���``�""'"'�
FINAL
Over 7 to 10 Incl. oATE / p�
LICENSED CONTRACTORS DI:CLARATION Over 10 to 50 Incl. _ '(� �� p�Z VALIDATIpN
I hereby affirm that]am licensed under provisionsoFChapter �—� Over 50to 70Q Ina FINAL J, �
9 (commencing with Sectlon 7000)of Divisio�3 of the puyi- Over 100 g� ., _��-�
ness and Profesaions.Code,a�d my license is in fnll foice and ���/'��--t
effect. Services .
License Number� l 7 Lic.Class 0-200 Amp.Under 600 V -__ . -
201-1000 Amp.Under 600 V. - .
Contract �" te Over 1000 Amp.or Over 600 V �
HOML OWNER-BUILUh:N llF.Ci,AHATTON Temp.Power Pole&Appurtenances I�
I hereby affirm that I am e-xempt from the Contracior'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&Cnnductors _._ � �(j J'],(�A `
� I, as owner of the property,will do the work and the Other lSee Complete Fee Schedule)— ---___ � .
� structure is no[ intended or offered fur sale (Sr.ctiun �-.o • o a s 2
7044,Busincss and Professions Code). � - . � .
CONSTRUCi]ON LENDING AGENCY - - ( � o j�j 5�
. I heeeby affirm that there is a cons[ruction lending xgency - -
for the perfnrmanca of the work for which this permit is pERMIT FEE � (Sub-Totall � a �����i o �
issued(Sec.3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) . �� �.L ll�—B�
I.ender's Address PERMIT ISSUING FEE k-� '`+
I certify thnt 1 have read this epplicnlion a�d state that the TOTAL FEE - �� �3
above information is correct.I agcee to comply with xll Coimty
ocdinances and State luws regulating ElecVical wiric�g, and . �
hereby authorize representati�es of thix County to enter upon , . .
the above-me � ed prupert �or inspection purposes. SEE-REVERSE FOR EXPL,ANATORY L:iNGUAGE - � .
''v �� � :
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