HomeMy WebLinkAbout1286A (9) N'°R"ERS•`°"PE"S^T`°N°E�L^RAT'°" � '6A66' � APPLICATION FOR ELECTRICAL PERMIT , �r,�
CE�806G 12�601
1 hereby attirm that I have a certificate ot consent tn self COUNTY OF LOS ANGELES - . BUILDING AND SAFETY LJ
insure,or a certificate of Workers'Compensatlon Insurance,or ,
a certiCed cnpy thereof(Sec.3800,Lab.CJ .
FOR APPLICANT TO FILL IN � JOB �
� Policy No. Cnmpany � qDbRE �
New Residential Bldgs.&Pools EACH NO. FEE
� Certified copy is here6y furnished. 1&2-Family,5q.Ft. S — S LOCALITY
� Multi•family Sq.Ft. — N A ST n
� Certifled copy is filed with the county building Inspectinn Residential Swimming Poals CROSS ST %i J
deparlment. OWNEROR �
� • � FIflM NAME . LZ•''
Date Applicent Outlets:Recl c�ight�Sw._� • �MAIL �
First 20 ADORESS
CERTIFICATE OF EXEMPTION FROht WORKfRS' Total No. �� Additionat CITV Tei No. }
COh1pENSATION ItVSURANCE � pLAnl CHECK d
(This section need not 6c compleled if the work i�volved � �1PPLICANT - �
by the permit is for one hundred dollars (SI00) or leu.) Lighting Fixtures First 20 ADDRESS �
Total No.� p'dditional ' �
i certify that in the performance of the work fnr which ihis Fixed Applianres Not Over 7 HP CITY Te1 No, U
permit is issued,I shall not employ any person in any manner . pERMIT w
so as to Aecome subject to the Workeri Compensation Laws. Ranqe_Heatef_D.W._ APPLICANT a
�
- Oven ,_Dryer_W.M._ ADDRE55 Z
Datc Applicant � Top _FAU _W.H._ CITY 7el No. •
Hood_Fan _Other_
NOTICE TO APPLiCANT:If,after making this Certificate�of Disp. _Room Air Cond._ UCENSE OF .
Ezert�ption, you should become subject to the K'orkers' F7EG.NUMBER Class
CompensaHon provisions of ihe Labor Code,you must forth- power Apparatus&Large Appliances DISTRICT NO.� PROCESSED BY
with comply with such provisions or this permit shal! 6e � Size&TYpe HP,KW,KVA,or KVAR
deemed revoked. . � � `C ��,t�eJ �
Up to 1 Incl.
Over 1 to 10 InCI. DATE
LICENSE�CONTRACTORS�ECLARATION Over 7o to 50 Inel.- �/'�c/-'�f2 .VALI DATION
1 hereby affirm that 1 am Iicensed under prrnisions ot Chepter Over 50 to 700 Ina FINaL �
9 (commencing with Section 7000)af Division 3 of the Busi• Over 100 aY I �
nes3 and Professions Code,and my license is in fuil force and �
effect. . � $ervices � .�
License Number Lic.Ciass 0-200 Amp.Under 600 V '
201•1000 Amp.Under600 V D,.Q,�� ��p,u� , �
CoMractor Date Over 1000 Amp.or Over 600 V � C �
HOML OWN@R-HUILDF.R DECLARATlON � ��� !^/o ��
Temp.Power Pole&APpurtenances .
I hereby affirm that 1 am exempt fwm the Contractor's S'9n with One Branch Circuit
License Law tor the fnllowin�.oAc��IcP�t[on 7n)i.c,a���[. Additional Sign Braneh Cireuits � a I G c��.u M
ness and Protessinns Code): �
' Misa Conduits&Conductors {������.�'�'L
� I, as owner of the properfy,will do 1he work and the pther(See Complete Fee Schedule)— . .
structure is not intended or ntfered for sale (Section . �.� � � (ti 9 p
7044,Business and Professions Code).
CONSTRUCTION LGNDING A(JLNCY � '.• • � (t 9 O� _
I hereby affirm that there is a construction IendinB agency '
for ihe performance of the work for a�hich this permit �s pERM1T FEE � ISub-Total� � � ��.� 8�8 Z
issued(Sec.3097,Civ.C.).
Lender's Name pLAN CHECKING FEE (One•Fourth Permit Fee) .
Lendrr's Address pERMIT ISSUING FEE �
�i certify that I have read this application and state that the TOTAL FEE ��. ��
above intormation is correct.I agree to complY W�th all Coimty .
ordinances and State la��s regulating Eiectrical w�iring, and �
hereby authorize reprcsentatives of this Cnunty to enter upon . '
the above-mentioned property(or inspection Durposes. SGG'REVERSE FOR EXPLANATORY LANGUAGE '
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Signature of Permi e_ Date � ' , � - -
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