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HomeMy WebLinkAbout1014A (5) � WUKKtiKS'CpM19PEN5A1'IONDECL.�IRATION 76A663 APPLICAT141V FOR ELECTRICAL�PERMIT � ' CE 8�6G(2-80) �. I herehy affirm th:�� � na��e a certificatu oe c<�nsent to�cel£ COUNTY OF LOS ANGELES BUILDING ANp$AFETY insure,or a certifica[e nt Wurkera'ComPensa[ion lnsurance,or a certified copy thereof(Sec.3600,i.ab.('.) FOR APPLICANT TO FILL IN J06 � !'/��-, � p�� � Yolicy tio. Cnmp�n1' — EACH NO. FEE ADORESS s���//"�74T��rF� New Residential Bldgs.&Pools - r� Cer[ificd copy is hercby furnished. 7&2-Femily,Sq.Ft. $ — g �OCALITY f��i�:�,. "�{� Multi-family Sq.Ft._ - NEAR[sT ❑ Certified r.uVY�%filed with the coimty building inspec[ion CROSS ST _ Residential5wimmingPools oWNEROR �,L1_�d f�ai�"� department. � ? FIRMNAME Y�In! ^s��f Uata Applicant . Outlets.Rec�Light ��.Sw.j� MAIL .{�y�r��' � F�ifs�20' - - '-- ADDRESS A��T�+'!� ....___ CER"fIGICAI'h�.Of FXEMPTION FROM WORKGRS' Total No(�+ Addiuonal " CITY ��-�j� i�7Ft"F-�ei No_�J � C(�MPENSA'LIUit''IN5UI2ANC'I�: , PLAN CHECK a /J APPLICANT o �. (This section need not be completed if the wurk involved ._� Lighting Fixtures First 20 � f t -qooaESS �--''� � l by the permit is for one hundxed doilais (5100)or less.) �� q�f�litional ---------- - � ' [ Total No.� - - ---- ----- . r I certifY fhat in t}�e p�rform�mw of Ihe work Cor�v'hich this CITV ..T-et'NoJ... Q � . Fixed Appliances Not Over i HP � � permit is issued,[shnl!nnt emPby any porsvn in:�n)'manner PERMIT � s�»t[n I�ecnme suhject to Iha WurAers'C'ompensntion Ls�t�s. j Ranqe=HBater_D.W._ AP_P_LICANT — _.,_,_____ — a � Oven _Dryer_W.M._ qooRess;,%- tA r Top FAU _W.H.— ''=- '� I)ate AVplicant_ CIT�"'� TeINo. J � '.� Hood—Fan .._Other_..__ . _ _ _ __. � NOTICE TO APPLIG'+�7�: If,afrr making this Certificatc of DiSp. _RoOm Air COnd._ LICENSE OR � t:xemptiun, y�ou shoutd become xubject to the Workers' f�EG.NUMF3ER Class � Compensation provision[;i>f tf�e Labor Code,you�nuet��o[th- _� ppwer ApparaNs&Larg¢Appliances ' DISTFiICT NO. PRQFfE55ED 6V wi[h cumply �aith such provisions or this permit shall be i i� Si�e&Typr.HP,KW,KVA.or KVAR - "!? �� ;7�+�„y,�a0 deemsd reroked. Un to 1 Incl. _..— ` — ,� - -- FINAL ; Over1to101nc1. oATE f �9 �.� VACIDATION LSCENSEU CUN'fRACTORS iIECLARATION _ Over 10 to 50 IncL . !hereby af'firm that 1 am licensed under procisions of Chapter � �-- Over 50 to 700 Ina � By A� /. . 9 (commencing with Section',000)of Uivisinn 3 of the Busi- i Over 100 - � Z:.tC��---•— , ness and Prnfr.ssions Cnde.and mv license is in full foree and " L"� effect. . ��' Services (� ' �I,icen+e Number__ Lic.Clasa`---- � 0-200 Amp.Under 600 V -- • 201-?000 Amp.Un:ler 600 V � Con[rHctor _ Date_ ___ �` Over 1000 Amp.or Over 600 V _ HOASIi OIYNER-BUILDER lll�Ci,ARA'ITC�N �a remF��o�^!er Pole&Appurtenances � *�Siyr.with One Branch Circuit — —� � I hereby affirm th:�Y 1 um exempt from lhe Contractur'.s ��p,�iditional Sign Branch Circuits Licanse Liiw Por the fullow•ing reason (Sectiun 7031.5, Rusi- 7�� ness and Profe�ssions Code): : Misc.Conduits&Conductors -�� Q�,/1{� �, us o�vner of ttie property,u�iU do tlie..•ork:ind the ���pther(Sec Complete Fee Schedule)-- s[ructure is not intended or ufYeretl for S:lIC (tiection � � _ {}o + • • �� 7044,Busi�ess and Yrofessions Code). -�--�-��-���-- --- — � • ��a]Q CONSTRUCTIUN LIiND[YG ACdI•:MCY - ----�--- : 1 hercU� affirm that there is a cunstructinn Iending agcne)' / / °�d °�S Q 7 i)F fur Ihe performance of LItL �cork for �chich this perrnit is pERMIT FEE (Sub-Tolall �-� issur.d(Sec.3097.Civ.C.). `��:� r �e�:i `�'"g'� . . Lender's N�me -- - �I PLAN CHECKING FEE (One-Fourth Permit Fee1 Lender's Address i pERMiT ISSUING FEE �'t I certify that [have read this apptication anJ state that die �TOTAL FEE ��� (� - aAnve informafion is correct.i�gree to comply with.ill C��imty --- � ordinances and St,ite lax�s regulatinq 1•:lectricn! wiring, and h�neby nuthori�n represen?atives of thic County to cntcr apon . the: ve-mentioned property or inspec[ion purposus. a SF.F.-RF.VERSE FOR E PLANATORY LANGUAGE ' 7 i / �t jl ���. /� l.7 O/ � . SiKna[u e of i'zrmitt Du[e � � � � � � ' I i � I � � ° � � � ; � -� ` � � 4 � � � ; I , � � � � . , i ? , ' i � � ; , ; ; � � ; � .;J . a I � � � I i: i � � i � ' i I r' :.. -�` i ? � � i � i: � i � I - i � I � i J� :- ! , : i � : ; -`� .; � ! ' ! I Y{ i ' ! I f , j 7 ° � � 3 i € � 1 � � i ' �" ' i ' I 'l' '� � ? ! E } : ' j � I � i. ? � 3 � .,3.. �r� i ! : i � - ! . � .�, s� ! � ; � : i � ' I ' � a ��,,"'1 � �� i � � � I � ' � � ; j - : .(r� � � � i : ' i �, � , � f � ` � . 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