HomeMy WebLinkAbout1030 N GOLDEN SPRINGS DR (7) woxxeRs'CO�iPENSATfONDECLARATION 76a663 APPLICA110N FOR ELECTRICAL PERMIT �
-CE-806G 12�80)
1 hereny aefirm that 1 have a certi£icate ot cnnsent to selt COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'CompensaHon Indurance,or -
a certified copy therrof(Sec.3800,Lab.CJ -
Q ,Jf�\ FOR APPLICANT TO FILL IN Jpg �n �
� PoliCy No ��.[flimpany !—'e��� — EACH NO. FEE AD�RESS V�
New Residential 61dgs.&Pools -
� Certified cnpy is herebY furnished. 1&2•Family,Sq.Ft. $ "" $ LOCALI7Y� p
Multi-family Sq.Ft.����—r — N AREST
Certified copy is filed�vhh the county building inspeclion , 3�,y � � CROSS ST �
department. � Residential Swimmin Pools , owNER Oa / ('� l
�J/��p� /� 7(�t/fil/4 W,�C� � ' ��, FIRMNAME G VG�1\
Date�� ✓ ApPlitanl 'I OutletS:Rer_Light_Sw.t�""�N A�ORESS �
First 20
CERTf1'1CATE OP EXE�IPTION FROM WORKERS' TOtal No.� Additional 5 ' � CiTY �Tei Na � �„
COMPENSATfON INSURANCE � �
� _ � PLA HECK a
. . APPUCANT. � O
(This section need not be completed if the work invoived Lighting Fixtures First 20 ADORESS U
by the permit is for one hundred dollus (SI00)or �ess•1 Total No. Additional �
I certify ihat in the performance of the wnrk for which this CITY Tel No. U
ermit is issueJ,1 shsil not em lo nn Fixed Applianees Not Over 1 HP
p p y y person in nny fnanner PERMIT f� ! W
eo as to hecome subject tn the Workers'ComPensation Laws. Range_Heater D.W._ APPLICANT G � G �G Y/� a
' ' Oven _Dryer_W.M._ AD�RE55� �b� .�a�(�— G
Date Applicant 7op _FAU _W.H._ CI7J e S Tel No. �— �
• Hood_�Fan _Other_
NOTICG TO APPLICANT:If,after making this Certificate of Disp. _Room Air Cond._ UCENS OR �
Fzemption, you should becnme subject to the Wnrkers' AEG.NUMBER Class �
Com�ensation prnvisions ot the Labor Code,�you must forth• Power Apparetus&L.arge Appliances DISTRICT NO. PROCESSED BY
�vith camply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVA
- deemed revoked. ' - � f n �;��/
' � . Up to 7 Incl.
FINAL
Over 7 to 10 Incl. oArE / VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl, � ��v
1 here6y atfirm that I am licensed under provisions of Chaptet, Over 50 to 700 Ina FINnL
BV
9(commencing with Section 7000)ot Division 3 of the Busi- Over 100 �
ness and Professions Code,and my license is in full torce and . � '
eftect. / r Services -
License Number:,�7JSL�-�� Lic.Class L�"I v 0-200 Amp.Under 600 V .
Q 201-1000 Amp,Under 600 V
Contractor Dale � =�� Over 1000 Amp,or Over 600 V � �
IiOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances �
I hereby affirm th�t I am ezempt from the Contrxto�'s Sign with One Branch Circuit
Additional Sign 6ranch Circuits . �Q�'$,�n
License Laiv for the following reason (Section 7031.5,Rusi• .
ness and 14ofessinns Code): - ��� � �2
Misc.Conduits&Cnnductors � �
� I, es owner ot the praperty,will do lhe wotk and the Other(See Complete Fee Schedule�— � •3 3 9.�.4 3
structuro Is not intended or oftered for sale (Seclian - ,
7044,Business and Pmfessions Code). � - _
CONSTRUCTION LENDINC AO}:NCY •,'3 3 9.4 3 c�
I hereAy affirm Ihat there is a construction lending ngency � � �
fnr the performance o(the wmk for which this permit is pERMIT FEE . (Sub-Totaq I �,�2�$2
issued(Sec.3097,Civ.C.). ' .
Lender's Name PLAN CHECKING FEE (One•Fourth Permit Fee) •
Lender's Address PERMIT ISSUING FEE '
�I certify that I have read this application and stste ihat ihe TOTAL FEE
above informa[ion is cortect.f agree to comply with all County �. �3 . �
ordinances and State lax•s regulating Electrical wiring, and .���
hereby authorize represmtatives of this County to entrr upon , � �
ihe above•mentloned property for inspectton purposes. - SEB'REVERSE FOR EXPGANATORY LANGUAGE �
�/�2GC1 1-��—�a"
, Signature of Permittee Dale � . '
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