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Home My WebLink About02_03_1983 - 2016 PEACEFUL HILLS RD WORKERS'COMPENSAT[ONpECLARATION 76A663 ppp�ICATION FOR ELE�TRICAL PERMIT � � � � . CE-B06G(2-80) . � I hereby affirm that I have a cerHttcate of consent to se1F COUNTY OF LOS ANGELES BUILDING AND SAFETY insure,or a certiCcate ol Workers'Compensation Insurence,or , , . a certiCed cooy thereof(Sec.3800,Lab.CJ � ' ' � FOR APPLICANT TO FILL IN JOB Vo(iry�9002123c�mPa�v—_ �� EACH NO. FE6 ADDRESS � 43= 2016��Peaoeful Hills . . � �- - New Residential Bldgs.&PpQI� . . . � �� Certitied copy is hereby furnished. , 1&2-Family,5q.Ft. �Ly S — S . LOCAUTVTR#32�J�I�QOO2 D].aTlnl'1C�{ BAL' . . Multidamily Sq.Ft. I Certified'oopy is Flled with the county building inspecfion . CROSS ST � �' � Residential Swimming Pools I department. OWNER OR Mc J.-BroCk & S�s � ' '� � � , "' . .. �-- FIRM NAME � Date 2 3 H3 APPltcant� M-C,P � . .Pl - Outlets:Recl Light 1`.sW.2- � � - � 3 00 ""A�� . 1698 Grees�briar Lane #224 . - �Fint 20 ADDfiESS . �: � CERT[FICATE O�EXEMPTION FROM WORKERS' Total No. 4 � Additionat � c�Tr $rea�.�j, rei No.529-6170 } - COMPENSAT[ON INSURANCE . . � y , � � , . PLAN CHECK � . O Cfhis eecKon need not be compteted if the wOrk invOWed AOPLICANT V _ Lighting FiXtUfes First 20 ADDRESS — by the permit is for one hundred dolisra (5100)or less.) � Additional � � � � � Total No. - . O I ceAify that in the performance of[he work for whkh�his Fixed Appliances Nat Over 1 HP � CITY. � -� Tel No. E... permit is issued,1 shall nat emptoy any person in any manner . PERMIT V 5-�a to become subject to tbe Workers'Compensation Laws. - Range_Heater D,W.� APPLICANT C � a "�..� . �� - . � . � Oven _�ryer_W.M._ AODqE55 P.O. BOX 2886 � z Date � Applicant� � Top _FAU _W.H..�. . — . - Hood_Fan _Other_ clTv POfIl011d CA.91769 T°'"°.� 627-0936 . . NOTICE TO APPLICANT:�If,after making this Certificafe ot Disp. _Room Afr Cond._ � LICEnISE OR 153378� YY C-10 F,xemDtion,.you should become subject to the Workers' REG.NUMBER C�ass Compensaiion provisions of the Labor Code,you must forih- �power Apparatus&Large Applienees DISTRICT NO. PROCES5ED 9V with compiy wfth such provistons or�this permit shetl be Size&Type HP,KW,KVA,or KVA - deemed revoked. . - � Up to 1 InCI. FINAL � � ' Over 1 to 101nt1. DATE �! q�✓� VALIDATION � LICENSGD CONiRACTORS DECLARATION - � Over 70 to 50 IncL ✓�`v �� I hereby affvm that�1 am ticensed under provisions of Chapter Over 50 to 100 Inc. . gy p'� . . 9 (commencing with Saction 7000)of Division 3 of the Busi• Over 1D0 - . ness and Protessions.Code,and my license is in full force and , ' � � � eftect. . � Services - � � � � - License Number 153378 . ��.ciess C—I.O 0•200�Amp.Under 600 V . �� 201-0000 Amp.Under 600 V � - co,,,r,�,o� el ectri cal Date ' 2�83 : Over 1000 Amp.or Over 600 V �G�G U A � � HOME OWNER-BUILDER DECLARATfON � Temp.Power Pole&Appurtenances . � �� -� , . .. .. __. . . . . .�' �_._ .._• . . _ . . _ _-- �-[ he--� affvm that�I am�exempt from the Contractor's� Sign with One Branch Circuit � , � � • � �ra 2 2 Lic� Law for the inllowing reason (Section 7031.5,Busi• Additiooal Sign Branch Circuits - - .. . . � ness a., Professions Code): 1 0�a 2 2 u - �� Misc,Conduits&Conductors � - � � I,-as owner oi the property,will do the work and ifie Other(See�Complete Fee Schedulel— O 2 2 H—H 3 � � structure is nob intended or affered for sale (Section , . � . - 7044,8usiness and Professions Code). . . � - - . � . CON51'RUCTION LENDINC AOENCY . , , I hereby attirm that there is a construction lending agency � � - � . - � for the pertormance ot ihe work for which this permit is pERMIT FEE (Sub-Totaq gq 72 �_ � issucd(See 3097.Civ.CJ� . � - ' ' � � �- � � � . Lender's Name PLAN CHECKING FEE ,iOne-Fourth Permit Fee) . , Lender's Address PERMIT IS5UING FEE . . . 10 5� � � � � 1 certify tha[1 have read Lhis�application and stale that Ihe � TOTAL FEE � ZOrJ ZZ � � � � above informetion is correct.I agree to comply with all Connty ' ordinances and State laws rcgulating Electrical wiring, and � � � � _ � � , hereby authorize representatives of this County to enter�pon , - _ , . . the above•mentioned property for inspection purposes. 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