HomeMy Public PortalAbout10144, 10128 BOGUE ST_Electrical_4/13/1984 WORKERS'COMPENSATION cafeDECLARATIO`flz�
consent
CE-663` 10811 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-8066 1,
' insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800, Lab. C )
Policy NoC�O / mpany hkz_ FOR APPLICANT TO FILL IN JOB L O
Certified copy is hereby furnish d New Residential Bldgs. & Pools EACH NO FEE ADDRESS
❑ LOCALITY
Certified copy is filed with th ounty buil mg i pec- 1 8 2-Family, Sq Ft. $ — $ f✓r li= G vT
NEAREST
tion department Multi-family Sq� Ft. CROSS ST.
r Residential Swimming Pools
Date49 -S�7 Applicant �� OWNER OR
FIRM NAME /�}`=/1r_
CERTIFICATE OF EXEMPTION FROM WO KERS' Outlets- Rec Light.4Sw._ MAIL
COMPENSATION INSURANCE First 20' ADDRESS
(This-section need not be completed F the work involved by Total No. Additional CITY • L ;r Tel. No.
the permit is for one hundred dollar ($10 0)or less.) PLAN CHECK
I certify that in the performance of he work for which this APPLICANT
permit is issued, I shall not employ ylperson in ny manner
so as to become subject to the Wo r1'Compe anon aws Lighting Fixtures First 20 ADDRESS
Total No '
Additional CITY Tel. No.
Date '� Apphcant Fixed Appliances Not Over 1 HP PERMIT
4NOTICE TO APPLICANT: If, after m king thi Certific e of APPLICANT /
Exemption, you should' become s bject to the rkers' Range_ Heater_D'W- _
Compensation provisions of the Labor Code, you,must forth- Oven _ Dryer — W.M — ADDRESS,33F�r
with comply with such provisions or this permit shall be Top _ FAU —W.H. — _
deemed revoked CITY Tel. Np>
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other— i ��C1� IZ
LICENSE OR
Disp. _ Room Air Cond. Class.
I hereby affirm that I am licensed under provisions of Chapter•9 REG. NUMBER � Qp`1a2./ C-z/
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO �� PROCE D BY
and Professions Code, and my license is in full force and effect
r Size &Type HP, KW, KVA, or KVAR O
License Number Lic C19-ss Up to 1 Incl FINAL V
��F( d ef��4-r< s Over-1 to 10 Incl DATE VALIDATION
Contractor_ _��CC , Date y'd Over 10 to 50 Incl O
❑ FINAL
I am exempt under Sec Over 50 to 100 Inc. BY �_ LU
Over 100
B&P C. for this reason Z
Date: Services, Swbd , MCC & Panelboards 1111111, OAF
Signature
0 -200 Amp Under 600 V
Signature 201 - 1'000 Amp. Under 600 V
EJExemption
1000 Amp. or Over 600 V
Exemption for Reg Maint Eject.
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 Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code) 9 6 8 8 8
I, as owner of the property, will do the work anMisc Conduits
d the &Conductors
o
structure is not intended or offered for sale (Section • Other (See Complete Fee Schedule)_ '0 0 0 0► �$ 2-
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY o'0 4 9. J C
I hereby affirm that there is a construction lending agency for 0 o (( 9,
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec 3097, Cw. C.). 0 3 1 4-8 4
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Le er's Address
Ic rtify that I have read this application and state that the TOTAL FEE
ab ve informatiop'is correct. I agree to comply with all County
or i `ances and tate I ws regulating Electrical wiring, and
e y authoriz repr sentatives of this County to enter upon L
t bove-men lone property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
• Signa ure of ermittee Date