HomeMy WebLinkAbout1004A -.....,"" '6"66' APPLIGATION FOR ELEC'fRICAL PERMIT {�
� CE�BOBG f2-80)
� nerehy affirm �het � ha��e a cert�ticete ot'consen�to self GQUNTY OF LOS ANGELES - BUILDING AND SAfETY � U
insuro,or a certificate o(Workers'Compensetion Inaurance,ar . �
. �n certifted copy thcreo((Sec.3800,Lab.CJ �
� Yolity N0. ComDany FOP APPLICANT TO FIIL IN JOB ! �i
New Residential Bltlgs.&Poals EACH NO. FEE ADORESS( �dV�C .
` � Certified copy is hereby furnished. 1&2-Family,Sp.Ft. $ —' 8 LOCa�ITY �j.JJ. ,L� « �
Multi-family Sq.Ft, '0. ' /
� �Certified copy is fited with the c nty building inapection u CROSS ST f /L�
Residential Swimmirp Poo1s p
department. ' F RM NAME 6'!
llate�ApD��cant Oudets:flec.�Light�Sw._S� �� f ADORESS I U �
¢/ first�O
CERTIFICATH QF EXEMPT[ON FROM WORKERS' Total No.� P.dditio�al
. COMPEN5ATION INSUI2ANCE � . P4AN CK � T T�I No. �� a
/ APPLICANT O
(This secHon need not be compieted if the work imolved .3 �c U
. by the pertnit is for one hundmd dollus(SI00)oi lesa.) ��9hting Fixtures, First 20 qooRess �
� Total No.� Additional �
1 certify that in tbe performence of the work for which this CITY � Te�No. �
ermit is issued.I shail not em fo an Fiaed Appliences Not Over 1 HP
p p y. y pereon in nny manner p�RM1T /� �
so as to become subJec�to the Workers'ComDensation Laws. Range_Heeter O.W.� pPp�ICANT I , 1 �/'lL p.
OVen _Dryer_W.M._ . AODREY3 — '+ � y
� Date Applicant Top FAU _W.H._
Z
Hood�Fan _Other�. q CI7Y �j . Tel No. �z� ,
NOTICE TO APPLICANT:If,atter making this Certificate of Diep._Room Air Cond._ o<- UGE E 7
E:emption, yau should 6ecome subject to the Workers' ' HEG.NUMBEF G 7 � Clns C��L�
Compensafion.D�o��sions of the Labor Code,you musf farth- Power Apperatus&Lar9e Appliancai OIS7RICT NO. PNOCfSSED BY �
. with comp�y with such provisions or this perrtit shelt be Size&Type HP,KW,KVA,or KVA � �
deemed revoked. � �
Up io 1 Incl,
FINAL
Over t to 101nci. oATe �Q° VAUDATION
LICENSED CONTRAC70R5 DECLARATION Over 10 to 50 IncL Io !J
� I here6y affirm that I nm�ic<nsed under provisions of Chapter Over 50 to 100 Inc. FINA� . ' � . .
9(commencing with Section 7000)ot�ivision 3 of the Busi� Over 1Q0 BY
. ness and Professions Code,end my License ts in!WI fotce and
ettect. �7 Services
, Llcense Number -� Lic.ClesslS C���✓� 0•200 Amp.Undar 600 V /`� . a . � �
�/ p'� 20t4000 Amp.Under 600 V
Contractor Dete .��� ��.e'� Over 7000 Amp.o�Over 600 V �� ��'1-Fti
1{OMEOWNER-BUILDER DECLARA7ION � �`� �`
Temp.Power Pole&P.ppurtenances
Si9n with One Branch Circuit 1 •°5�.5�
� 1 hereby affirm that t am exempt from the�Contractor's Additional Si9n Branch Circuits
Li4ense Law for the following reason(Srction 7U31.5,Bust- , �..� _��y
ness a�d ProTessions Code): � . � °°
Misc.Conduits&Conductors �
� I,as owner of the proper[y,will do the work and the p�fier{$e¢Complete Fee Schedule)— �a j 2 �� �
� structure u not latended or offered for uie (Section , �
7044,Business and Professions Cade). �. ,
CONSTRUCTION LtiND1NG AQENCY �
f hem6y affirm cha[ there is a cons�ruction lending aQency � � �
for the perPormance uf the work for which this permi� is pERM�T FEE � (Sub-Tota11 �
issued(Sec.3097.Civ.C.} � � -
tender's Name PLqN CHECKING FEE (Ona-Fourth Permlt Fee)
LendePs Address PERMIT ISSUING FEE �J� ,
cerfify tha[I have read this apP���ation and state that the T07A1 FEE �� .j� ' �
bove informati n is correct.I agree to comply with a11 County .
rdinpnres an State Iaws reguieting Electrical wiring, and � � ,
ereby autho ze representati s oP this County to enter upon _.
ie above-m tioned p operty or impution purposes. , SEE'REVERSG FOR EXPLANA70RY LANGUAGE � � �
}^ ��
a[ure af permitte Date � � �
. . . 01CNER•33UILDCR DECLw�cr..,....
, <' 't'. ,.
� � 1 hereby afrrm.th5t I am esempt tcom the Contiacwr's ,
.__�...__.....__�.. ... �
' - APPROVALS . OATE iNSPECTOas .. � Licensc l.aw for the follo�cinc reason fSeetimi 70J1.5,
- SIGNATUR[ � � 6¢iHzes.c anrl.Profeasiwis Code):�Any-ci�y`ur coun(y
�� - - ,��� � -� - TEfN°.POWERPOLF. ' '"' "�"-' -" � ' - �- ti��ticli rCquirCS O (1CIRtlf !o Cartstrtt[i, a7tC/, irnpro�'C,
.. � - - - � � dernoiish,or repair crr}�sra�ct:ne,pri��tn its itsumme,
, - --' ' 11NDER5Ll�6YVORK - .
. . . clso rcquires d�e applicant for suth perrrut to fife a
��- �� -� � -� � � nOUGHCot�ouir, . � - � --- . � � �� ., signed smrernerrt diar he i�ficertsed.A«rSuarit.lo dic
�� � � -- --�� VdtRtr�c ' � � g �'m/���'� ' ➢rorisiats of d�e Coritrneror's Licertse,law(C1mPter 9
� ��J . . . (enmmenttng fvith Src�ion 7000) of Oirrsiar� 3 oj thc
- • � . F1xTuftES � � � � � - . , � � Ri�siness and Prefessions Code/ or t+�af he is exerrtpt
. __. _ • � � Jlzerrfroni 6nd ll;e 6asis for`the a((eAcd ezempfior..Arty
___ .. . � ' . _.POWEF.'FNTHORIZCD ' - rio7atiarr of Seidon 7031.5 byan}'apPt�rmv fo�o penrti(
;.._.__. ._ ... UTIL17v CO_NOTIFIED �•. .� . '. . sxe6jertr the applicml!to a civi!penafty oJ r:ot rmarc N�mr
, � . ---._. .. ... . ;. . . .. 'fr�r hintdred doffars(5500J.: . . . .,
. . - _. . _.. _ . . �FwnL . l.'it�✓i O�= �i 40rt1 � , � � 'D 1,ac o�dncr ot tlic proPerty lcill do thr�cork,and
� � � NOTes ' , , - " -,; ���� ,. ,@�e shucture is not intendcd or offered for s�lc. , ,
, : - .. -. _- -. . .-. . - _- � , � �� (Sec, iO4�t,Burirress artd Professinns Code: The.Com
. . � . � � �� � ' , . �- . . . [ractor's Licensc�Law docs nof appl}� fn arc oiorrer of
- _ , . . . property xdro 6ui(ds ar impro��es il�ereon,nrtd wfio does
' -. ' � � . �- . .. � sucl: x�ork fiimseff prm•ided that such irnpro��entenfs
- - t .. are not-iufei�ded or offered for sa7e. IJ. Howerrr.�r)tc
, - _ . _ -. -. . . . . � . buildi�+� or iinproro•ement.is sofd witliin one��ear of
. conrp7etiat, fLe ownenbuilder wi!! Gare die b«rden
��. : ... : . .. ..... .:. ._ ._ _ � . .._ � . ,
. . � � . .. � of.p�oring ILat !ic did v�ot 6uild Or irnprou•e for tNe
. . . , .. . � Purpos^nf safe.J� . .
" - - . - � . , . . • I�m e�empt under Sec. .
��.. � , . ..,,:_ ', � '""� -�- .
-- - - ,.. . Ti&P.C.for this re�smi '
� _ . .. _ ,
_ i
` Date '
, _ 0��ner _ _
_ . _ _ .. ___ .. _. ... .
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