HomeMy WebLinkAbout1222A s PEhs^T'°N°E�L"R"T'°N '6A66' APPLICATION F4R ELECTRICAL PERMIT ,r�
� � � - CE806G(2�801
1 herebl' affirm that t have a certit'icate oe consent to se�e COUNTY OF LOS ANGELES BUILDING ANp SAFETY- U
insure,or a certificate of Workers'Compensation Insurance,or � �A R
a certifie copy1 t1hereof(Sec.3800,Lab.C.) �O� �
I P�olt y No. ^~� �ompany 57�� F�RM FOR APPLICANT TO FILL IN DDRESS
! New Residentiai Bidgs.&Pools EACH NO. FEE
� Cettified copy is hereby futnished. 7&Z�Family,Sq.Ft. "' � LOCALITY �
�Certified copy is Ciled with the cwnty bUilding inspect�on Multi�family Sq.Ft. CROSS ST V� 1 R
��, department. I/11p �/ ReSidential5wimming Pools OWNER OR �^ C'�{C
� bate App�ic �^ Outlets:Rec� �Sw. MAIM NAME lr.• �Y�f V J L��1�
Light Fnst2� I� ADOFESS f..J� 1 / � ` IT"�
CERTIFICATE OF EXE TION FROM WORKERS' Totai No. � �� Additional CITV ��, �Tel No. ' Cj �
COMPENSA'IION INSURANCE � �
. PLAN CHECK a
APPLICANT �V
(This section need not be completed if the work involved �, �� .
by H�e permit is for one hundred doilars (3100) or IessJ Lighting Fixtures First 20 qooae5s �
Total No:� Addilionel p
I certify that in the Oerformance of the work for which this CITY Tel No. U
permit is issued,I shall noi emptoy any person in any maaner Fixed Appliances Not Over 1 HP ERMIT �
� L f3 V�[��tS �
- so as to become subject to the Workers'Compensation I,aws. Range_Heater,D.W._ - ApPLICANT CoLe+N� a
Oven _Dryef_W.M._ ADDRESS �� t f r�,�}-P �� �
Date Applicant Top _FAU _W.H.^ CITY�, �-�• Tel No.Sg y��(] ~ �
Hood_Fan �Other_ �
NOTICE TO APYLICANT:IF,after making this Certificate of pisp. „_Room Air Cond,_ LICENSE Oa .y
Exemption, you should bemme subject to tNe Workers' � � REG.NUMBER �` laas
Compensation provisions of the Labor Code,you must forth- power Apparatus&Large Appliances ISTRICT NO. PROCESSED BY
with comply with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVAR i(Y�
deemed revoked. 1� � 1\
, Up t0 1 InCI. FINAL
LICENSEU CONTRACTORS DECLARATION Over 1 to 10 Incl. � DATE /� �� �y�
Over 10 to 50 Incl. Zg� VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. F INAL -
9 (commencing with Section 70p0)of Division 3 0!the Busi- Over 1D0 �Y ^' �y
ness and Nrafessions Code,and my license is in full force and. Y E���� �
effect. Services �
License Number��L4JClass � 0-200 Amp.Under 600 V
�t�1�Dt�I A��Q������ . 201-1000 Amp.Under 600 V
Contractor k� Date� Over 1000 Amp.or Over 600 V
HOME OWNER-BUI4DER DECLARA O�T����— Temp.Power Pole&Appurtenances� .
I hereby affirm that I am exempt from the ContractaPa Sign with One Branch Circuit _ �
License Law for the following reason(Section 7031.5,Busi� Additiona)Sign BranCh Cireui45
ness and Professions Code):
� I, as owner of the property,wi11 do the work and the Misc.Conduits&Conductors
simeture is not intended or offered for sate (Section �ther ISee Complete Fee Schedule)— .
7044,Business and Professions Code). . ' �c:� 2 2 2 a
CONSTRUCTION LENDING AOENCY .
1 hereby affirm that there is a construction lending agency
for the performance oF the work for which this Dermit is . �� �.� � �2 �
issued Sec.3097,Civ.CJ. PEFMIT FEE (Sub-Total)
Lender's Name PLAN CHECKING FEE {One-Fourth Permit Fee) J � �2�����
Lender's Address PERMIT ISSUING FEE � (�j � � �2��� �U
I certify that i have read this application and state that the TOTAL FEE . (�.,` , � O,,�7—8 2 �
abovQ informaHon is correct.t agree to comply with all Counry �
ordinances and Staie laws regulating Electrical wiring, and
hereby'aut6orize te➢resentatives of this Coun[y to enter upon
t above-mentioned proper for inspection p poses.
�r� � � � SEE�REVERSE FOR EXPLANqTORY LANGUAGE
ign�ture oP Permittee Dat �
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