HomeMy WebLinkAbout0850A (6) i _-_-` �' .y�..
� '"°RKERS`�°"^PE"SAT'°"°E""RAT'°" `' ` p�'"°"'"�,87 APPLICATION FOR ELECTRICAL PERMIT
..76Afib3 `\.
I hereby affirm that I have a wrtiffcate of consent to self �E.� �.,
insure,or a certifico�n of Workers'Compensation Insuronce, COUNTY OP LOS ANGELES DEI�T.OF Pl1BLlC WORK$
or a cenlfied copy thereof(Sec.3800,Lab.C. j
Polic No.�� '-� Com an �� �� €-� - FOR APPLIChNt 70 FILL IN 10B /� 1 .
Y P Y AooRESS �3J� �J�Y'iit�ot,(�'�4•r� �`�I�:t� �f�.
�Cenified topy is hereby furnished. � New Residenlinl 81dgs.&Pools EACH NQ FEE .
Certified�copy is filed with the�county building�nspec- 1&2-Fpmily,Sq.FI. $ — S LOCALITY j iC�. �,. "�a,�^ '
�tion deparimen�. Multi-family Sq.Ft. — NE,4R[57 ,
CRO55 ST.
Oote�-F� �f4�-f�V,x` ,/ Rasidenfial Swimming Pools OWNER OR
Applicanl. FIRM NAME .:�1h� .�I • -
���/g„-�_CERTIFICATE OF EXEMPTION FROM WORKERS � OuHets:Rec�.Ught_Sw._ � qoDRE55��!��'a °s. ' t�P. i..�k�.fa� 1!� ` kt��f �
QY COMPENSATION WSURANCE First 20 �� ,?
(Tbis secfion need not be completed if}he work involved by �Total No. Addilional CITYS ,�:� �L� Tel.No!C _,!!•
the permit is for one hundred dollors(S10D)or less.) PLAN CHECK .
I certify Ihal in ihe performance of ihe work For which�his APPIICANT
permit is issued,I shall not employ any person in qny mariner ��Lighting Fixtures Firs1 20 ADDRESS �
sa as io become s�bject ta�he Worker.z'Compensmion Lows: �
� � . Addition�l
� To�al No. CITY Tel.No.
Date � Appli.cont � ��Fixed Appliances Nof Over 1 HP peaM�T .
NOTICE TO APPLICANT: If,'after making ihis Cerii{��a�y o{ APauCa.TION 12Q -- ''64 xr'R�(:�+. �
Exemption, you shoald become sub;ect �o ihe Workers' Ronge— Healer—D.W. _. �� �
Compensotion provisions oi the Labor Code,you must forth- Oven —Dryer --W.M.— ADDRE55 ct�C' 'Sn ,�.• -
with comply with such provisions or this permit shall be ; Top — FAU —W.H.—
deemed revoked. CITY �� , ��� ,� ^Tel.No.t� "- . ,� z
� Hood —Fan --_-Other.— •' , � ��i �� � :
LICENSED CONTRACTORS DECLARATION �. Diso. _ Room Air Cund. — <<CEPJSE OR ly„^-;.F�� .
I hereby affirm th�t I am!icersed urder provisions of Cnapler 9 y , REG.NUM9ER "L 9 � Class.}3 ��W �'
(commencing with$edion 7000)of Division 3 of.the Business �Power Appawtus&Large Appliances DISTRICT NO. P OCESSED Y �}
ond Professions Code,and my license is in full force ond effect. _ �a �yQ .;.� ,
, ���-�/ � Size&Type HP,KW,KVA,or KVAR
License Nomber_�r�aa t.��lic Class � ��;� i Up to 1 Ind. fWAL ..
. . / t r Over 1 to 10 Incl. DATE�( {:� VALIDATION A d
Coniractor ���'���✓/,�� �. Daie �` . F'��� < < `� ;.F-
. r �' Over iQ b 50 lad. FINAL
❑ I am exempt under Sec. ; Over 50 to 100 Inc. BY j�` r ,°;a
B.8P.C.for this reason Over 100 '�'1✓� ;,�.�
� � � Date: 'Serviees,Swbd.,MCC 8 Panelboards � . '<,Z
� �0-200 Amp.Under 600 V
;. Signature 201-1000 Amp.Under 600 V
t O O�er 1000 Amp.or Over 600 V
f,!, Exemption for Reg.Mainc Elecc �
� SINGLE FAMILV xTemp,Power Pole B,Appurtenances
HOME OWNER-BUIIDER DECLARATION ��Sign with One Branch Circuit
1 hereby offirm'hm I am exempt from the Comroctor's ticense i: �
Law{�r the following reason(Seciion 7031.5,Business and �Additional Sign Branch Circui�s _L1 •?i.C/�.
Profec.sinns Co�:)
�� '�Misc Conduifs&Gondudors y7�- a a 4 u 1
� ❑I,as owner of the propeity,will do�he work and�he `Other See Com lete Fee Sthedule °, h
strudure is not intended or offered for sale(Section 7044 � P �— � m e � 2.l (
Business and Professions Code).
CONSTRUCTION LENDING AGENCY `.'� '��G,'�
I here6y affirm that�here Is a mnshuction lending agency for '
�he performanca of rhe work for which this permit is issued PERMI7 FEE (5�6-Total) �P�� � �—U�
f (Sec�3097,Civ.C.J. ':
� ', . � PLAN CHECKING FEE � , '
Lender's Npme ,s� .
' � . PERMIT ISSUING FEE � �
Lender's Address O �'�
� -�� I ceriiiy that I have read thls application and stoie tha�ihe TOTAL FEE Q; .
obove information is corren.I ag�ee to comply with oll County .,
ordinances and Sta�e laws regulating E�ecirical�Niring,ond
hereby au�horize re�resenidtives of ihis Cou.nty to enter upon .
ihe above-�pentioned property for inspection purposes.
� SEE REVERSE FOR EXPLANATORY IANGUAGE
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