HomeMy Public PortalAbout4824 BALDWIN AVE_Electrical__ (2) WORKERS'COMPENSATION DECLARATION 76A663CE-806 10/81 PLICATI N FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE-806G
or a certificate oa WorkCrs'Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec. 3800,Lab.C.)
Policy No. Company. FOR APPLICANT TO FILL IN JOB
❑ Certified copy is herebyfurnished. EACH NO. FEE ADDRESS
New Residential Bldgs.& Pools _
❑ 1 & 2-Family,Sq.Ft. $ — $ LOCALIT
Certified copy is filed with the county building inspection
Yk
department. Multi-family Sq.Ft. — NEAREST
CROSS ST.
Residential Swimming Pools OWNER OR
Date Applicant - - FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL .7 '�/
COMPENSATION INSURANCE Outlets:Rec— Light Sw. —'" DDRESS j,�( r /J��J�VVI,y AV
(This section need not be completed if the work involved by the First 20 ,a
Total No. Additional CITY j q,404-' • L j Tel.No. ✓l q�/-: G%•�
permit is for,one hundred dollars ($100)Or less.) PLAN CHECK
I certify that in the performance of the work for which this permit APPLICANT
is issued, 1 shall not employ any person in any manner so as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
' Total No. CITY Tel,No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making. this Certificate of APPLICANT .9l�
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
provisions of the Labor Code, you must forthwith comply with such, Oven _ Dryer _.W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top —.FAU _ W.H.
CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_
I hereby affirm that lam licensed under provisions of Chapter 9LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. Class.
REG.NUMBER
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. Z;:�
Size'& Type HP, KW,KVA,or KVAR 0
License Number Lic.Class Up to 1 Incl. FINAL U.
Over 1t 10 Incl. DATE �,-• VALIDATION O
Contractor Date Over 10 to 50 Incl.
❑ FINAL V
I am exempt under Sec. Over 50 to 100 Inc. BY W
BAP.C.for this reason Over 100 . AJ N'
Date:
Services,Swbd.,MCC & Panelboards a , Z
0- 200 Amp.Under 600 V V
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint. Elect.
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the*Contractor's License Law =E y;.
for the'following reason (Section 7031.5, Business and'Professions Additional'Sign Branch Circuits m
Code):
Misc. Conduits:& Conductors
® I,as owner of the pro ert will do the work and the structure 3 I I t"i'" -
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule)
and Professions Code). , • >-i;is �° - r
CONSTRUCTION LENDING AGENCY _:HEC
I hereby affirm that there is a construction lending agency for the :,
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) 5-H (lf�
Civ. C.).
PLAN CHECKING FEE
Lender's Name _?� i_
Lender's
I i
PERMIT ISSUING FEE _
Lender's Address _.I`ab::
I certify that I have read this application and state that the above TOTAL FEE 7, -
information is correct.I agree to comply with all County ordinances
and State'laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned "
proper for inspection purposes.
�t � !_� j��f-•y j SEE REVERSE FOR EXPLANATORY LANGUAGE
/Signat fur,,7'�j�VPdr-rmittee .'1�Jam. Date �/
't •r r' ..1..
10
� Y1.•
os /-A 4 tow PPLICATION FOR:PERMIT.:,, .
`
DEPARnIENT OF BUILDING A.ND SAF .; .�
COUNTY OF LOS ANGELES ELECMC_ '.'.,
WM J FOX CHIEF ENGINEER �
-t DISTRICT NO GROUP ZO E PERMIT No. +.'
NATURE OF INSTALLATION
72.6E
WIRING FIXTURHS 9E171 ICH �t
RtiC![f G OY READY FOR D TRISSUED
HEATER _ r ST INSPECTION
RANGE POWER FIR
SION4 MISCEL NEOUS t ! '}y
APPLICANT FILL 'E.AVILY OUTLIN,E•DORTION1�1,Y:;JOB
NAME
1 "
U
ADDRES9 J .
N EAR EST '
CITY N7 CROSS 9T.
COUNTY
CERT. NO. '� EXPIRr,,9
DMS RI ION OF WORK z ' MAILS
NUMBER OF OUTLETS ON CIRCUITS O I ADDACS0 a,
LOCATION BY ROOMS CITY :1 TIL NO.
LIGHT OUTLETS 5W.1 PLUGS nVT. 1 AM THE LEGAL POSSH9>�0 OF TH ' ABOVIp Lp�
ANG=LZSTI
B =LINTY CTtf!_�? OVA 1!' CAT
CIRCUIT ' A B C D E F I G H . ;y
LIVING' ROOM -LaCTRICIAN. •i
/ 1 AM THE LEGAL OWNER OR THE PROPERTY D"CRI D
GDINING ROOM _L.. ABOVE. Y �f
i
awwltR, Y=a
CORRECTIONS
ENT. HALL ^I p
I HALL NO.
l''. 1 ,' 't•' t •. � � CJI•t`i
FRONT PORCH t
' OUTSIDE '
SERV. PCH. I ^�^i~}� Q
obtiio. No.
CL09ETr.�.r4L' ��r.� i '�. . }: •• ' 7 `t ?u;- Q' Rxa INS
C OS ET"" V
7-7
54('Ry .r
- . y.t +, - e. - 2�,•. �ia /- "o V • ..4re61
TOTALS ::i �+
e { T
NO.�OF.'OUTLETS �4 YAPPROVAI,S'
r 1 n • x . r.. .u+
NO. OR FIXTURHS T t i i .:tti r%�y 1?� t`yf � ZDAT$pit,rd?y�t}IfKCTORJ/`IIAa11LrvEt
NO. .OF MOTORS * H 'P. f 'f: ,CONDUIT r
NO.' OF` SIGNS TRANS. ; WiR1ftiG � � t uLF
4 X ?
. / , ,.4r }. .I .• l 'J�:l: 1ii (t 3... A1C 76.
NO. HEATERS / 9 �•J rlXTuwcg
MISCELLANEOUS S' a„• POWER V r1 ), t.
PERMIT FE6
KF .. ,i,rJ +rf1JiL ti �jN, i..i�'f�r^r p rAta jfk�� 4»C i
TOTAL PEE S .FINAL v r ..dlVvr y
c;.