HomeMy WebLinkAbout0448A (6) - . WORKERS•�o„PENSAT�oNDE�LARAT�oN:� �E$o6��Z.eo, , APPUCATION FOR ELECTRICAL PERMIT
I hereby attirm ihat 1 have a certificate or consent to se�r ' . COUNTY OF LOS ANGELES BUILDING AND SAFETY �
insure,or a certificate of Workers'Compensation lnsurance,or - � � �
a certiTied copy thereot(Sec.3800,Lab.C.) � � �
- � - FOR APPLICANT TO FILL IN � . �pg T
� PolicyNo. Company � ADDFlESS jJ` �Q, �
New ReSidential Bldgs.&PoOIS EACH NO. FEE �
� Certified copy is hereby furnished. � � 1&2•Family,Sq.Ft, S — 5 LOCALITY ��� �
❑ � Multi•family Sq.Ft, — � NEAREST �
Certified topy is filed with the county building inspection CROSS ST CS
departmenL � Residential Swimming Pools OWNER OR 1-._,.._ lA
� ' � ' FIRM NAME ��.�w 'Y
Date Applicant Outiets:Rec._Li9ht_Sw._ MAII
� FirSt 20 AODHESS �
CrRT(GICATL 01'LXGM1IPTION FRO�f WORKF.RS' Total No. AAditional
COAIPHNSATfON INSURANGi� . CITv Tel No. }
PLAN CHECK a-
APPLICANT Q �
(This section need not be comp�eted iP the work involved U
� by the permit is for one hundred dol�ars (5100)or less.) Lighting Fixtures First 20 ADDRESS . -�� �
Additionat
�i certify that in the pertormance of ihe work fot which th(s Totel No. . C�TY Tel No. �
ermit is issued,I shatl not em lo an erson in an manner Fixed Appliances Not Over 1 HP
P P Y Y p Y � PERMIT � W �
so as to become subject to the SVorkers'Compensation Laws. Range_Heater D.W._ APPI_ICANT S a
� N ,
r� Oven _Dryer_W.M._ aoDaEsS �'Zv '����¢i,
EDate�Applican� Top _FAU _W.H., '��3 r
i Hood_Fan _Other_ CITV Tal No. �
;NOT1C1:TO APPI,ICANT:If,after making ihis Certifi ate of Disp. _Room Air Cond._ LICENSE OH
Exemption, you should become subject to the Wnrkers' REG.NUMBER- ���2 Class
�.Compensation provisions of the Labor Code,you must forth- power Apparatus&Large Appliances oiSTRiC'r No. PROGESSED Y
lvith comp�y with such provisions or this permit shall be �
�deemed revoked. Size&Type HP,KW,KVA,or KVAR �� - .
Up to 1 Incl. a'�
FINAL
LTCFNSLD CONTRACTORS DECLARAT[ON Ove�1 to 10 InCI. DATE � VALIDATION �
Over tO to 50 Incl. � o� ��i
I hereby aiCrm that 1 am licensed under provisions of Chapter OV2f SO t0 100 If1C. FINAL
BY
9 ([ommenting wi[h Se[tion 7000)of Division 3 at the Busi- Over 100 �- .
ness and Protessions Code,and my license is in full tarce�nd - �
effect: � Servires �
License Number Z'��pZ Lic.Class OQDO Amp.Under 600 V . ,
207•1D00 Amp.Under 600 V .
Contractor �S Datc � Over 1000 Amp.or Over 600 V � _
� IIOStE OR'NER-BUILDrR DECLARP.TION Temp.Power Pole&Appurtenances , 'O 4 4.H A
Sign with One Brench Circuit ��
I hereby affirm that f am ezempt from'the Cnntractor's qdditional Sian Brench Cireuits ��� � ��2
License Law for the fottowing reason(Section 7031.>,Husi• � e • .
ness and I4ofrssions Code): � � • �I�•��2 Q Jr 0 �
' - Misa Conduits&Cnnductors
� I,as owner of the property,will do the a�ork and the Other(See Complete Fee Schedule)— ' •:° •2 Q J��:�
Slructure is not intended or offered for sale (Section , � � �
7044,Ausiness and vmfessions Codey . I O 3 O.=S-�
'��� CONSTKUCTION LIiNDING AQENCY
� I hereby affirm that there is a construction lending agency � � -
t� for the performsnce of ihe work for which �his permit is pERMIT FEE � (Sub•Totall . �Z(f .
issueJ(Sec.3097,Civ.CJ. � �
Lender's Name . PLAN CHECKING FEE (One•Fourth Permit Fee) . �
LendcPs Address PERMIT ISSUING FEE � O � -
1 rertity that I have read thie applirotion and state that the TOTAL FEE . �('f �� -. _
above information is correct.I agree to comply with all County -
ordinances and St�te lan^s regulating ElectHcal wiring, and
hereby authorize represtntatives of this County to enter upon -
theabove•mentinlied property Por inspectinn purposex. ' SHE'REVERSE FOR EXPLANATORY�LANGUAGE �
Signature of Permittee �Ua e�� � � �
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