HomeMy WebLinkAbout0951A � �o��LaaAr�oN 76AB63 APPLtCAT10N FOR ELECTRICAL PERMIT �
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I hereby affirm thet I have a rertificate of consent to setf COUNTY OF LQS ANGELES BUILDlIVC�AND$AFETY
insute,or a certificate of R�orkers'Compensation Insurance,or �
n certified copy thereof(Sec.3800,Lab.C.)
FOR APPIICANT 70 FILL IN Jpg
�� Policy No. Company AOORESS �I � � '
� � New Residentlal Bldgs.&Poois EACH N�O. FEE � ��P �
� Certified copy is hereby furnished. , 1&2-Family,Sq.Ft. $ —' g LOCALITV � �,
QMulti-family Sq.Ft. EA ES7
Certified copy is fiied with the county building inspection ResidenCial Sw�mming Pools CROSS S7 � �LQ IW1�N =
depaitment � p�qM NAME TL��Y I ' '
Date Applicant OuTlets:Rea�Light_Sw.� qDDRESS � Q.(in R)
First 20
CERTIFICATE OF EXEMYTION FROM WOftKERS' Total No. Additional CITv � Tel No.5'�(� ','r O
COMPENSATIpN INSURANCE .r
_ � PLAN CHECK a
(This section need not be compteted if the work involved dPPLICANT .��/�, �
6y the permit is for o� hu�ced do0azs (SI00)w IessJ ��9hting Fixtures First 2D aooAESS V
� � Total No. Additional
2
I cetHfy tha[in the performance of the work for which this CITY Tel No. O
ermit is issued,[ahall not em o an Fixed Appliances Noc Over i HP �
p y person in any manner PERMI7
so as to become subject-to the r ers'Co ens[ion L:�ws. Range_Heater_O.W,^ APPLICANT '�ME � W
a
Uate����Q�A Oven _Dryer_W.M._ AOORESS v)
Applicant� Top. _FAU _W.H.._ CITv � Tei No. ?
� Hood�Fan ..�Other�
� NOTICE TO APPL[CANT:If,after ma ing t-� Certifica[e of Disp. _Room Air Cond._ LICENSE OFi
Exemption, you shoWd become sub to the Workers' RE .NUMBER � Class
Compensation provisions uf the Labur Code,you must forth- Powe�Apparatus&Large Appliances DISTPICT NO. PROCE38 p BY
with comply with such provislo�s ot this permit shall 6e Si�e&Type HP,KW,KV A,Dr KVAR /7 ����(/
deemed revoked. U �f
Up to 1 Incl. FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 701nc1. oaTE ��/a� �J� VALIDATION -
Oaer 10 to 50 Incl. �
I hereby effirm thnt 1 am licensed under provisions of Chap[cr Over 50 to 700 Inc. FtNAL
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 BV
ness xnd Professions.Code,and my license is in ful{force and ,
effect. 5ervices
0-200 Amp.Under 600 V
License Number Lia Class
201-1000 Amp.Under fi00 V .
Coniractor Dete Over i Q00 Amp.or Over 600 V �
HOME OVJNER-BUILDER DECLARATION Temp,Powar Pole&Appurtenances '�
I hemby affirm that I am exempt from the Contractor's Sign with One Branch Circuit : C�'S.1 P�
License Law fos the following reason (Section 7031.5,Busi- Additionai 59n Branch CirCuits #, 4 ` c � .2
ness and Profeasiona Code): - �
Misc.Conduits&Conductors � � � � s�(����.
� I,as owner oS the property,will do[he work and the �pther(See Complete Fee SChedule)— - �
structure is not intended or offered for sale (Scetion �C C tc r�-
7044,Husiness and Professions Code). E �� �-`-
CONSTRUCTION LENDING AOENCY f�Q 4.y.p,.�
I hereby affirm tha[ there is a construc[ion lending agency -
for [he perf'ormance of the work for which this permit is pERMIT FEE �(Sub-Totall �
issued(Sec.3097,C�v.C.). . .
Lender's Name � pLAN CHECKING FEE IOne•Fourth Permit Feel
Lender's Address PERMIT ISSUING FEE - �
I certify[hat I have read this application and state that ffie TOTAL FEE �
above information is correct.I agree to comply with all Coimty
ordinances and Sta[e laws regulating Electric�l .v�ring, and
herehy a orize represen tives of this Couoty to enter upon .
the abo entioned�op y r inspection purposes. �
q SEE�REVERSF,FOR EXPLANATORY LANGUAGE
� �
Signature of itie Date � � �
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