HomeMy WebLinkAbout1354A w�aK��:�ss��o�,�'LNSA710NDECLARATION )6A663 APPLICATION FOR ELECTRICAL PERMIT � �
CE-BOGG(��801
I hereby +tfirm �hat 1 heve a cer�ificete nf consent to xlf COUNTY OF LOS ANGELES . BUILDING AND SAPETY
In�u�e,or�certificate ot Workers'Cnmpensa�ian Insurance,or ("7� �1
�cntlfied copy tl�ereof(Sec.J800,Lab.C.) ' '7 i—�SJ�iti i f"'1
Pollc Nn.����� � i�NL:.;/M.�it�+:C�, FOFl APPLICANT TO FILL W �... ..i�•�. !OA ..t ' � .' 1 i'
y �L'omp■nY ADORES � 'r��'�'r)���. �'
New Residential Bldgs.&Pools EACn NO. FEE � ,'-, �
❑ Certifie�co �shere6 furnished. � S — S � LOCALITV' ;���:f �
PY' Y . . . . 1&2•FamilY.Sq.FI.
� Cerllfied co � Alulti•family Sq.Ft. , 'A
py is filed wi�h�he tounty building Insprclian CHOSS ST Ll�Cf�til►h!<_i�' [j�L A CI���"/�.
Jep�rtment. • - Residential Swimming Pools OwNER OH
l)ale I.•�J i�l/Ap0linnt "riJrli CG�1:.7�[�. . . . . , FIRM NAME'�.A AIIJI �li:�C L � AI�7.t/.C�:
Ou112tS:ReC.�Li9h1_Sw.� MAIL "
Fusc zo aooREss �i,Y,�'.%I h-, G:lAltilfJ i a�
Cf:HTIFICATC•OI'EXL�IYTION FROAi WOHKF:IlS' Total No. AAAiti0nal CITY ;,lJ�1L f��(�7" ' T�I No. �K
, C0�11'LNSATION INSVRANCE , PLAN CHECK U U
('fhi� ceciion nred not be�comple�ed if ihe uo�k involved r APPLICANT ` L !'
I�y the permlt is fnr one hundreS dollus (5100)or less.) Ligh[in9 Fix�ures Fir:c 20`���� " qD�RE55 �n�
� Totel No. Additional
1 cerlifY Ihnt In Ihe performonce�ot�he wark fnrµ�hich this CITV TH No.
perinit ts I�sueJ,1 fAall not emplay eny persnn in any manner Fi*ed Appliantes Not Over 1 HP �
PEAMIT
.n■�tn hecome subjee�to the Warkers'Compensetion Lews. Range_Hcater_D.W,_ arp�iCaNT�"! / �C C�G1':T�C EC'• �"✓G
. . . , . . •. ' Oven _�DryB�_1Y.M.__ AOORESS ..1.s r:� i r��.Af l�./v
I���a Appllcent � ToP _FAU _LY.H._ . ' '� �
Hood_Fan _Other_ c�7V �=,C/Jir`,;;r�/F�- T�I No.„j�c�'�'/�/
N()TICI:TO AI'PLICANT:If,afler'making�this Certificate of Disp. _Room Air Cond� LICENSE OR � �_{
I�Lcmrllun, ynu shoul� hetOme'Subjett lo�'Ihe \Vn�kers' REC..NUr+19ER r`�1�'�� ,. C�aff ���1�
�_umpen�a�lon provlslonf of 1he Lebor Code,you must fnrlh• power Ap�eretus&Lar9e Appliences OISTRICT NO. PROCESSED BY -
wl�h comply wi�h sueh provisions or Ihi:.permit shall be Size&Type HP,KIY,KVA,or KVAR �
.leemed revoked. . i'�^..
. .. � . . : , ,,,, . .; � �� UP to t Incl. _ . �
� � •• • FINAL
Ovcr 1 1010 Incl. DATE
I.ICI�:NSF.D CONTItACTORS�ECLAR�TION Over 10 to 50 Incl. �—j b.-._�� VALIDATION
1 hcrehy effirm thet 1 em licensed under'prnvisions of Chapter Over 50 to 100 Ina FiNp ' .
��(r��mmencing wilh Seclion 7000)of Division 3 af the[3usi• Over 100 '� �
nr��and 14nfr�slnns Code,end my license Is in full force and t� � nf/� '�3>.L1/L
<««<• � � Services '
.� • • ••• �
I.leen�e Numher ...��i�r 4C.%3 Lic.Cl�si �^���L� �'200 Amp.l}�der�G00fV f � . � � .
201-1000 Amp:tlnder G1�0 V 1 '3p — •( • •��'_(; •
�'nn�r�c�nr �' ���� ������ �-�D�te'� 1�� �� � � Over 1D00 Amp.or Over G00 V �. �
_ ._ :�. . e .�4, �i
IfU�IF.OWNLR•IlUILDGIt�ECLARATION ' Temp.Power Po�e&Appurtenences
SPECIAL
I herehy effirm �het 1 am e�em t from Ihe Conlractor'� i S�9nwithOnaOranchCirtuit �
P Additional Si�n 6rench Cirtuits INFORh1ATION
I.iien�e I.�w for the followinQ reesun (Seclinn 7071.5,fiusi-. ON REVERSE
nr��and IYnfcsfions CnJe): ��n.i ('._��! .
. hlisc.Canduits&Condunors SIOE .
� I, a����wner uf the propetty.will An lhe work and Ihe '� Othe�ISee Complete Fee Schedulc)—
�Iructure Is nn1 tntended or'offered fur sale (Section , �
70a4,Dudness end 1'rofessions Code).
CONSTItUCT10N LLNDINC AOLNCY
1 hercl�y affirm th�t Ihere Is a rnnstruetion lending agency
1�.� the perfnrmance uf the work for which �his permi� is � " `��
�„ue��S�c.)097,Civ.C.). PERMIT FEE (Sub•To�al) . � �p,)
I.c��Jar'�N�me pLAN CHECKING FEE (One•Founh Permit Fee)
1r
I endrrt Address PERMIT ISSUING FEE �y )G ; • ,I
I ceriify �li�t 1 have read �his upplicallon and staia�he� ihe TOTALFEE 3 -�' r O�` �
J��r.e mformeelun is[orrect.1 agree m rnmply wlth all Connty ^1 ` �j �
����hnence� anJ State laws reguleting I:lectrieal wiring, and \] p '
i����rhy amhorlee represen�stives of this Cu�nly to enter upon ��
il�e� ��ve�mentloneA praperty fnr Inspect�on pyrpn:es. SEE'ItEVCRSC FOit I:XPLANATORY LANGUACf:
� i� I ;
-t lr • ; —:' � r,�l !i � • �-r;—:s'f �
Sitn��ure of Permillee Date •
I .
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��cl�'d �U��1�,1;a rv 1 /,.�7��-y n -�-v�rv��i"� .
�--}/ 7 '�a�8 `d°� 1l tv�j�d ?�Y�o �� �c���