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Home My WebLink About1422A � . . , -��..,..,. . ,. �— ATION DECLARATION 76A6s3 76/ai ,J� ' I hereby ef,�rm th�a certificate of consent to se�f insure, ce-aosc APPLICATI4N FOR ELECTRfCAL PERMIT `t t . or a certifica}e of Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY j„j copy thereot(Sec 3800.La6.CJ �..,,�e PoliCy Na. �— �Comp2ny J'�G �Nih._ FOR APPLICANT 70 FILL IN JOB �j ❑ GertiFled copy Is�ereby f�rnishetl. EACH NO. FEE ADORESS Za/�.�� M�Lk�E�C�j New Residentizl Bidgs.&Pools 4DCALITY Gertified coDY ' fi with the coun}y ,� iu}„i ection ��2-Family,Sp.Ft. $ ` $ f NEAREST depar e L/ �� / Multi-family Sq.Ft. CROSS 57 _� Residentlaf Swimmin9 Pools Ow�Nea oa �1 . Date ApplicaM FIRM NAME CEF7IFICATE Of EXEMPTION FROM WORKERS � � � � � MAiL Outlets�.Rec Lyht Sw. COMPENSATION INSURANGE Ao0RE5S S (This section need not be completed It the work lmoived by the Pirst 20 permlt Is for one hundred dollars($100)or Iess.) Total No. �7 Additlonal CITY Tel.No. I certify that in the perFormance oF the wo�k for which this permit PLAN CHECK APPIICANi j� is issued,1 shall not employ any person in any manner so as to become subject to the Workers'Compensation laws. Lighting Fixtures First 20 ADDRESS � Additional � Total No. CITY Tel.No. � �ete ApD��cant Fixed Appliances Not pver 1 HP ' �NOTIGE TO APPLICANT: If, after making this Certificate of PeRMiT Exemption,you shwld hecome subject to ihe Workers'Compansafion Range_ Heater_D.W. _ APauCANi - provisions ot the Labor Code,you mus}forthwith comply with such Oven_ Dryer_ W.M._ ADDRESS provisions or this permit shall Ce deerrred revoked. �� Top .___ FAU _ W.H._ CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood— Fan _Other_ I hereby affirm thal 1 am licensed untler prOvisions of Chapter 9 p'�sp. —Room Air Contl. _ LICENSE OR w�Ory Class,�.s �COfnlnEnCing with Section 7000)of D'wiaion 3 of the Bu51nB55 alld REG.NUM9ER ��G7 1 Professions Cotle;end my liCenSe i5 in tUll fOrCe end effeCt. ppy�er Apparatus 8 Large ApplianCeS OISTRICT NO. PRQCESSE � � Size&Type HP,KW,KVA,or KVAR O �_, b License Number �� Lia Glass j Up to 1 Incl. FINAL � � O contractorp�L�def.��+�"J� oate�F� �°er 7 to t0lncl. DATE � �� VALIDATION � Owr 70 tu 50 MCL � . H � FINAL ( '_I I am exempt under Sec. Over 50 to 100 Ine. gY 't yV,� Over 10Q � � Q• B.&P.C.tor this reason CA Services,Swbd,MCC&Panelboartls ,� ► Z` . ate� 0-200 Amp.Under 600 V - Signature 201-1000 Amp.Unde�600 V . 7 Orer 1000 Amp.w Over 600 V ! Exemphon for Reg.Maint.Elect. S)NGLE FAMILY Temp.Power Pole&Appurtenances � HOME OWNER-BUIL�ER DECLARATION Sign with One Branch Circuit � � I he(e6y atfirm ihat I am exempt from the CorAractor's License Law ptlditional Sign Branch Circuits for t��e fo�lowing reason(Section 7037.5,Business and Professions . . Cod.l: � I,as owner ot the properTy,wi11 do the work antl the structure Misa Canduits&Contluctors . is not intended or offered for sa�e(Section 7044,Business Other(See Compleie Fee Schedule)_ � �� l�� and Professions Gode). �• °� CONSTRUCTION LENOING AGENCY I hereby affirm fhat there is a conetruction lentling agency for the � • •�{L,(r() performance of the work for whiCh this permit is issuetl(Sec.3097, p�RMR FEE (Su6-Totall Ci¢C.). . � o r .�1,t�i)!.J�; � PLAN CHEGKING FEE Lender's Narne � �9,�7'�� PERMIT ISSUING FEE Lentler's Adtlress Q� I certify that I have reatl this application and state that the above TOTAL FEE information is correct.I agree to wmply wiih ail Gounty ordlnances � and State laws regula}ing Elechical wiring, and hereby authonze representa[ives of nty to enter upon the above-mentioned � � � �� propert kfor ir ect�n urp � SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Permi}tee � �Dat� - . T�i�i3� �/�'T3�J! � 'MM�fK�EJ'�M " • ,.. , , _ �-�-.�• e�s�er. li►. +ic •.9,,,,, .. - _ _. . � _ � � ' APr�IiOVALS DATE � �WSPECiOR'S � - �-B(1M-D�EFi� � �� - SIGNATURE � . � �. '�TE7a�P_PELNER POLE� � I hr;mby afiirm thzC 1 am ezempt irom the Ccnirar,ta�'s Licen.4e �-- � � L,aw fm ih�fo;lowing�eson(Sec,tiQo 7031.5,8ustr�ss aKl UNOCft9LA8 WORK � � Pro(essi��,ns Code):.An�cit o'r osunf�wh;ch r _.. _ . S Y _Y eqllre,a Pe*mit R6UGf1 f,'JkDUIT . . .. fo cor�sMd9ls.aN�r,iw�rwt',N.emclrsh,'or rcpej�chm�;.pria "` �� 1 . fo its issuancs,atso re�ui�es the applicant ta such permit to 61e �,WIRING . . - . � � a si,qned shzfeir:eni iha!he is licensed putsuant to the provisions . FIXTURES � -� � � � . of the Cw�iractsu's Lrcense Law(Chapfer 9 fcammencing wifh � � � � Sea[ion 7D00)af Oivtsinn 3 of thc Husi,�ess anc�Piofessions � � POWER AiJTHORILED Code) or tY,".he fs e�mmpt iherelram and tbe basrs!or tbe �. ' U(LITY Gq.NOTtFtcO ,.—. . allayed exempSor,.Any vio(atim of Sxffon 7p34.5 by a y , . . � � app6nanf tw a permrt subpcts[he apP��a ciNl penalty . � � FINAL� �" FyytgY OY2 FYOYLT � of nO�f-mtar,than fiw hundred doflars($500/: � ' ' "' � ' � �� kOTE� � � � LJ{�a5 OWf1Ef Of lhP,prppGYSy YJi'�.I(�o thP.WOYk,&Iid fhB shucture is noY Iniend�d or ofsered tor.sale. � �. . . . . ._ � � � . (Sec.JOd3,Business ar,tl Profzssicns Cotle: 7he CantracEa: , , Lrcense Lav�Coes not ap;,!y to�7 aw�er of propzrty who buii:Y . -- - - � , or improves thezmn,and who does sucfi wwk himsetl provide - _. .... ... . _ _ . tnat s��ch im,provemerrts are nar intendetl a�offeretl tor sa��.� ; ,.. - . howe�er,ffle 6Uilding ar Inyxovemen!Is Soltl Within one year= . .. , .. . . cannleGon,Che owner-builder wl'1 ihve ft�e 6unie,n of prwing fh - � - - . . he did nei twiid or improve for the purpase a/sa1e.) - •. �i�� 'i, . . , . ,. � , .,... , � � . .,.... - - � �I am sire�p[under Sec`.�'�"� . ._.. 6&P.C.tar ihis reason � � � . �, � � Qate-.. .... �� . Owner _ ' . . _.. . . .. _ . . . _ .�'. r,'; . . , .