HomeMy Public PortalAbout9042 ACASO DR_Electrical_10/10/1986 TION
76A66
WORKERS' COMPENSATION,hove certificate
of corse CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
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 No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS Z
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. EEE
S Ft. $ — $ LOCALITY
El Certified copy is filed with the county building inspec- 1 & 2-Family, q
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' //,/ MAIL
Outlets: Rec Light. Sw
COMPENSATION INSURANCE !�gg�,p�'� First 20 � /t,� � ADDRESS
(This section need not be completed if the work involved by Total No. y J Additional r� CITY Tel. No. ���
the permit is for one hundred dollars ($100)or less.) PLAN ECK
1 certify that in the performance of the work for which this PPCA
permit is issued, I shall not employ any person in any manner
so as to become subject to the Wore, 'Compensation Law Lighting Fixtures First 20 5 ADDRESS
Total No. Additional
����6� CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this he
of APPLICANT
Exemption, you should become subject to the Workers' Range_ Heater_D.W.
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood Fan _Other_ CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR ,
hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO, OCE ED BY n-
and Professions Code,and my license is in full force and effect. r- p U
Size&Type HP, KW, KVA, or WAR' d
License Number Lic. Class` Up to 1 Incl. FINAL Cr
Contractor Date \ Over 1 to 10 Incl. DATE 7�? VALIDATION
F-1 Over 10 to 50 Incl. FINA Ltl
I am exempt under Sec. Over 50 to 100 Inc. BY a
B.&P.C. for this reason Over 100
Date: Services, Swbd., MCC & Panelboards
0 - 200 Amp. Under 600 V
As F–
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
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):
I, as owner of the property, will do the work and the Misc. Conduits& Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 2 5 6 Q 8.A
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 'Co 0 0 0 0.2
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE 1 9 ° 2 9.2 5
Lender's Name
PERMIT ISSUING FEE /0 -z> a ° ° 2 9 2 5 5)
Lender's Address
I certify that I have read this application and state that the TOTAL FEE A 11 Q a 8 6
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby ay4horize representatives of this County to enter upon
the Vie-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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S-19rraTure of Permit ee Date