HomeMy WebLinkAboutNo Permit Number .�����F.. r .p� . ..
VJORKEFS'�M ENSATION DEGLARATIO� 78Ass3 io/s7 � T1 '1 J/
� I hereby affirm that I have a certificate of consent to self insure, ce-aosc APPLICATION FOR ELECTRICAL PERM� 1 ,,/�'�y
or a certificate of Workers'Compensation Insura�e,or a certitied COUNTY OF LOS ANGELES BWLDING AND SAFETY��1J �
copy thereof(rSeeT�c.3800.Lab.C.1 �I,��...r�� r
PoliCy No��i�!��7�S�SLCOmp2fry�Ni/YJFIV.I�{.. FOR pPPLICANT TO FILL IN JOB
❑ Certified copy is hereby fumished. ��G` . EACH NQ FEE ADDRESS'.. ��S•. ,,S
New Residential Bldgs.&Pools
� 1&2-Family,Sq.Ft. $ _ $ LOCALITY �� �
Certified copy Is fileU with the county huilding inspection
rt ent. � � Multi-family Sq.Ft. NEARES7 G l
Oate � � Appiicant v`��°A' ��-*Y-�� CR0.SS 57. -Q�{, � q/
Residential Swimming Pools OWNER OR
FIRM NAME �'�
� CERTIFICATE OF EXEMPTION FROM VJORKERS' putlets:Rec—llgttt_Sw.� MNL ,��+
COMPENSATION INSURANCE ADDqESS G /�',tJc� � �.
(This sect{on need not be aompleted if the work InvolveA by the First 20
permit Is for one hundred dollaro($700)or leas.) Total No. Adtlitional CITY � Tel.No.
I certify that irl the pBrfo�m2�e Of thB wo�k for which this permit . � PLAN CHEC �
APPLICANT
is issued,I shail not empby any parson in any manrrer so as to
become su6iect to the Workers'Compensation Laws. L'ghting Fiztures Firs}20 ADDRESS
Total No. Additional CITY ?el.No.
Date Applicant � Fized Appliances Not Over 1 HP PEFMI7 ��
NOTICE TO APPLICAPIT: If, afEei' making this CertN�ate of r/ �
Rarge� H�atef_ D.W. _ APaL�CANT
fFrFlmption,you ahould become subject to the 4Vorkers'Compensation ,� / -
rions of the Labor Code,you must forthwith comply with such Oven_ Oryer^ W.M._ ADDRESS
pwasions or this perm'rt shall be deemed revoked. Top _FAU ^ W.H._ CITY y, 7e1.No� �y�
IICENSED CONTRACTORS DECLARATION Hood_Fan _ Other_ ��� ����
I haraby affirm that I am licensed under provisions of Chapfer 9 DisO� — Room Air Cond. — uCENSE OR Jf�.�� Class.0�
(commencing with Section 7000)of Division 3 of the Business and REG.NUM6eR [.�'v
Professions Code,antl my license is in fuil force and effect. power Apparatus&Large ApPliances �iSTRiGr No. PaOCESS ev
t�,/+ Size&Type HP,KW,KVA,or KVAR S Q
License Number A Lia Class Up to 1 Incl. FINAL
C�
�-<<-�"�� Date Over 1 M 10 Incl. Q p
Con[recroi�� y a �� Over 10 to 50 IncL DA� 7�L��6 �A� U
❑ FINAI
I am exempt under Sec. Over 50 to l00 loc. gy a
B.BP.C.forxthis reason Over 100 �
� , Services,Swbd.,MCC&Panelboards , Z
Date: , 0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V �
❑ Exemption for Reg.Main},ElecG - Over 1000 Amp.a Over 600 V
m .eK..P��•e.l�b��� �s.�
SINGLE FAMILV Temp.�6e&Appurtenances N � �
HOME OWNER-BUILDER DECLARATION Sign with One Branch Gircult
I herehy affirm tha}I am exempt hom the Contractw's License Law AddiPional Sgn Branch Cirwits
fr""^=follox•ing reason(Section�037.5,Business and Professions
C .
MiSc.CondURs&Gonductors �� 3 q� �
❑ I,as owner of the property,will do the work and the structure pther See Complete Fee Schedule)_
is not intended or offered for sale(Section 7044,Business ( ► . �
and Professions Code). +�• • ° ` • -
CONS7RUCTION LENDING AGENCY � �
I hereby aTfirm that there is a construction lending agency for fhe � �
performance of the work for which this permit is issued(Sec.3097, pERM1T FEE (Sub-Total� �
Civ.C.).
- PLAN CHECKING FEE I •C O rJ.r7 O
Lender's Name
. PERMIT ISSUING FEE Q
Lentler's Atldress
I certify that I have read this application and sfate that the above TOTi1L FEE �
information is correct.I agree to comply with all County ordinances
and State Iaws regulating Electrical wiring,and hemby authorize
representatives of this Counry to enter upon the above-mentioned U Y������
�rope' for Ine(Seetion(wrpoeen. ,
n SEE REVERSE FOR EXPLANATORY LANGUAGE �
r � �
Signature of rmittee Dete
—.___--_—— \
k .
� � � � APPROVALS DATE v WSPECTOR'S • OWNER-BUILDER DECLARATION
. � . SIfNATURE -
� � �. . TEMP,POWER POL.E � � I hereby affirm that f am exompt from the Contractor's License
- - - . Law for tho tollowing�eason(SecGon 7031.5,Business a�d
� . UNOERSLAB WORK � Professions Code):Any ciiy or county which requkes a permit
� ROUGH CONDUIT . � to r,rons(ruct,alFer,irryomve,demolish,w repair any StrocWre,prla
to its issuance;ako requires Gie applicant for such permi[to file
�� WIRING a signed siatement that he is licensed pursuaat to ffie provisions
� FIXTURES �� of fhe ConUactor's License Lpw(Chapi2r 9(canmencing wif77
� . . Section 70001 of�ivision 3�ot the&rsiness arrd Protessims
� ' � POWER AUTHOR2ED _� —� Code} a that he is crempt therelrom and ihe basis fw the
� UTIUTY CO.NOTIFIED alleged ezemp!ion. Any viofafion oi Section 7037.5 Uy any
a/gr1lcant for a permit sulNects fhe applicant to a civl!penaliy
� � FIPlAL �yLL"CY 072 F7'OYLL � ot rrot more fha fivo hundred doUars($5Q0):
❑I,as owr�er af lhe property wiil do the work.antl[he
NOTES structure is not intended or ofiered for sale.
. � � � (Sec.�044,Business and Professions�Code: 7he Cantrac2or's
tice�ue Law dces not apply t0.an owner ot property who�+Ids
� � � , . � � � or impraves therea�,and wha does such wak himseff F ;d
� . . ihat such improv�:ments are not intentled w olfered lor sare.ft,
� � � � � � � . howevei,the building w im,nrovemen(is sold within one year o7
compfetion,Fhe ownerbuilder wit!have the hurden of prwing tha�
� � . � he d!d rrot bui(d w lmprove for the pur�wse o!sale.) �
.. I am�exempt under Sec. ,
B&P.C.for this reason
Date
... . � , .. ., _. - �. � . Owner