HomeMy WebLinkAbout0604A (4) �� y
4�' OMC-�TIOWDECLAR4TION — 76A663 �0�81 APPLICATtON F�R ELECTRICAL PERMIT
� I hereby affirm that I have a certificate of consent to self insure, cE-eo�G �
or a certificate of Wo�kers'Compensafion Insurance,or a certified COUNTY OF LO$AN�ELE$ BUILDING AND SA�ETY
� copy thereof(Sec.3800,Lab.CJ
POfICy No. COtilpany FOR APPLICANT TO F1k{�N JOB � - e � A r
❑ GertNied copy is heieby furnished. Ne�v Residential Bldgs.6 Pools �H NO. FEE Aooaess 9 J
� Certified copy is filed with the county building inspzetion 1&2-Family,Sq.FL $ — 5 LOCALITY `� Y+
d0p9�SRIEf1f. Mul[i-f2fnily Sq.Ff. NEAREST
GHO55 ST. h
Date Applicant _ Resitlential Swimming Pools �yN,�q�R
/�� FIRM NAME � '4T,.
CERTIFICkTE OF EXEMPTION FROM WORKERS' Outlets:Rec '�Light�SL Sw.— �'"'�
COMPENSATION INSURANCE � aDDRESS
First 20
(Thir eootion need rrot be complatod ii the wark involved by ihe Total No.� Additional
permM is fw om huntl�etl deHars($1001 or leea.) CITY � Tel.No.r�' -
I certHy thai in the peKormance of the work tor which this permit ��ati criECK ._.�—
IS ISSU2d.I Sh211 flOi EfI1pI0y a�y KJ2lSOn in 3ny rtlannef So a5 fo APPLICFNT
hecome subject to the Workers'Compen tion Laws. Lighting Fixtures First 20 / RDDRE55
� 9 / �pty /�' Additional
SS� .����[ / Total Na.� CITV Tel.No.��
DateiLs/-1.�—RPPlicant - 'G�� �.• � ixe Pliances Noi Over 1 HP
NOTIGE TO APPLICANT: If, after making ihis ertifica� PEHMrz
Exemption,you should become su6ject to the Workers'Compansat o� Range,� Heater_ �W. _ APPUGAN7 �� <i.J�v��/'_'
proviams of tFie Labor Code,you mua[foRhwith comply with such Oven_ Dryer_ W.M._ ADDRESS q
provisions or this permit shall be tleemed rewked. Top _ FAU _W.H._
LICENS€D GOHTRAGTORS DECLARRTION Hood— Fan _ Other� ��T� �G�Y4'�^'Q••�- Tel.No. ��m.�
I hereby atfirm tMat I am liconsed under provisions of Chaptar 9 uCENSE OR
(commencing with Section 7000)oF Division 3 of the Business and Disp. _ Room Air Contl. _ REG.h`UhreER ciacs.
Wofessions Code,and my license is in full force and ef(ect. oI57RiCT NO. Pfi0eE5sED eV
Power Apparatus&Larce Appli2nces
Size&Type HP,I(�i',KVk,or KVAR J �
License NumGer Lia Glass Up[0 1 Incl. FINAL ,�7 .�-� �4"7
Over 1 to 10 Incl. �ATE C--�'.—�� VAIJDATION �
Gontr�ta flaFe `� - �
Over 10 to 501nc1. �.FINhL
❑ I am exempt untler Sec. Over 50 to t001nc. gy ���„
B.&P.C.for this reason Over 700 �'
Services,Sw6tl.,MCC&Panelboartls ► �
Date: — 0-200 Amp,Under 600 V �-
Signature 201-1000 Rmp.Under 800 V
❑ Over 7000 Amp.or Ovsr 600 V
Exemaion for Reg.Maint Elect.
snac�e FnMa�v Temp.Power Pole&Rppurtenances :�.6�4�
, HOME OYVNER-BUILOER DECLARATION Sign with One Branch Circuit �� • •C
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign&anch Circuits
for the tollowin�rezson(Section 7037.5,Business antl Professions � ° � 1 C�5 C�
Codel:
� 1 C„50�
Miaa Conduits&Conductors
�� I,as owner ot the property,will do the work and the stiucture p�her�See camplete Fee schedule)_ 0�.� � —�i 7 � -
is not intended or otferetl for sale(Section 7044,Business �
and Protessions Code).
CONSTRUCTION LENDING AGENCY
I here6y affirm that there is a construction lending agency�or the
performance of the work fo�which this permit is issued(Sec.30�J7, pERM1T FEE (Sub-Tatal)
Civ.CJ.
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUWG FEE �C� S�'
Lentler's Address
I certify that I have read this application and state that the abovc �TAL FEE t`
info�mation is correct I agree[o compy with al�Gounty ordin2nces
and Stafe laws regWating Electrical wiring,and hereby authori:e .
representeNvee ot this Gounty to enter upon the above-menfioned
ty Jp inspecEion aes.
� SEE REVER5E FOR EXPLANRTORY LANGUpGfi
� ___�f ��� �, �--��.3
Signature m Date �
c
t� . � •� � � .
.�`�'��.'� iN5�tC7oF;�S OWN�R-8UlL6�R�CLRRRft�lh
Aavaova�s � oarE�rti��tF
� TEMP.PONJEP FOLE �hereby affirm tha!I am exr�mpt trom[he Contrar.tor'�Uceose
— — �-- Law fcr the followln�reason(Seiction 703Y,5, Busrrress end
UN�ERSLAE�UlORK Professions CodE):Any cl.ry or co�rny whlch requires a permlt
RbUGH CONDUIT � Eo consvucK alier,lmprove,demnA�sf�,or repelr any sGucture.pnor
- ' , , � to ils issuance,also R quii�s f%e a,�liaU�t lor suCh pen»it fD ffle
� WI'�ING � � ;���� a s(grted siatemc� ih he is lic�nsed pursuant to the prwlslwrs
RXTURES ��� � of tho Conhaofor's Lrc 3sm LaN (Chaptca 9 fcammenclnn wlfh
� i.�.. _ Secffon 7000)o/Divlsia� 3 af ihe 6usiness an�i R�o�essrons
FOWER.ALITHORIZED Code) or ihat he L s:2mp!therefran tmotl the 6z,is for thr
a0eyed excmpUon, Any viplaalon ot SectBxi 7031.5 by sny
� � UTILIiY CO.NOTIFIED
_ a,.�plloant Ior a pennir su6/ects the apptica�!to n pivif penaRy
�FIi�dFSL j}Yttf:Y Gt2�'Y(172t of not mnrz then five hunAretl rlol±:,rc,�($SOtl);
NGTES ❑�,ns w�ner of thr property will do ihe work,ancl tho
S�tUCtL�YB i9�U:init3f�d��,'-fl pf pflCfc',C7 fOi S1.+:0.
(SEc.704A,pus,ocss encr FYoiessi�ns Coder T7�e ConNactor's
--� ---- �-- lJcense Law does no:a;;yly tc an owne:'of prc�eity who bu/kis
� a'irr�rcves t0�7rcor5,antl who do:s such vnuk fiirnself�vavidod
� "-- --- - fhat sUch Improvemen(s arp noi intendea a dfei�f(or sat2.If,
� how�ver,fhe buitding or lmpro�omeni 1s sold wlthin a��year ol
� —�—�--- --- — � ----- complvtinn,tho owncr-bui.'�er wr.4 have the burdmn of p;ovAn�tha[
he[fid ncf bui(d or Jr�ravr tor(he Gurpos�or sete.)
.— _—...._.�..__...�___.__-..�_..—..�. i am exempt ander Sec.—..� ..
------- — -------- B E P.C.tor khi�reason__..�._�_,
�� Date
Owner