HomeMy Public PortalAbout9014 ACASO DR_Electrical_7/3/1990_outlets • - 1P;;�RKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT
E ( "� a CE-806G
I,he rly affirm that I have a certificate of consent to self insure,
or a certificate of Mb ers Compensation Insurance, or a certified- COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 3800,Lab C) ? �j�
Policy No Company ={ '(��� - FOR APPLICANT TO FILL IN JOB
E] 7
Certified,copy is hereby furnished New Residential Bldgs &Pools - EACH ADDRESS
NO FEE LOCALITY
E] ' Certified copy is filed with the,county building inspection 1 & 2-Family,Sq Ft
$ i — $
NEAREST
depahment Multi family Sq Ft CROSS ST'-
Date a Applicant 7 "(p ">fryYivH. Residential Swimming Pools OWNER OR �1
°• FIRM NAME '`vd/V ���v' LY.
.CERTIFICATE OF'EXEMPTION FROM WORKERS'; " ' .8w MAIL
Outlets Rec—L Light
COMPENSATION INSURANCE ADDRESS'-_ 76 2 Z ti[A y4-✓�
(This section need not tie completed if the work involved by the First 20 ,
permit is for one hundred dollars($100)or less),' Total No_� Additional CITY L!�• y�f �A. �aLTel No
,I certify that in the performance of the work-for-,which this permit E _ PL`AN CHECK
is issued, I shall not employ any person in any manner so as to ` APPLICANT
become subject•to the Workers'Compensation_Laws ' Lighting Fixtures First 20 ADDRESS
Total No
Additional CITY Tel No
Date ! Applicant 7 � N ic+i1- Fixed Appliances Not Over 1 HP, r
NOTICE TO APPLICANT If, after,making this Certificate of PERMIT
n
Exemption,you should•become subject to the Workers'Compensation Range_ Heater_ DW APPLICANT -r#*A( NIH
provisions of the Labor Code,you must forthwith comply with such'" Oven.— Dryer_ W ADDRESS_ ag _ SDr GVl2 .
provisions or this permit shall be deemed'revoked Top ,_ FAU '•WA _
LICENSED CONTRACTORS DECLARATION Hood — Fan �. Other= CITY Tel No
I hereby affirm that,I am licensed'under,provisions of Chapter 9 LICENSE OR
(commencing with Section 7000)of Division 3 of the Business and Disp — Room Air Gond Class p
REG NUMBER'• 52 Z Z'S p'.
Professions Code,and my license is in full force and effect DISTRICT NO PROCESTA
• Power Apparatus&Large Appliances
Size&_Type HP,KW,KVA,or KVAR
License Number 7- 77•,x" Lic Class "-- - ' , •
g Up to 1 iricl FINAL Q
Over 1 to 10 Incl DATE V r��
VALIDATION
❑
Contractor d!l/t1iNA 'Date '7l;�90 +• 0 '—� F Over 10 to 50 Incl , jj
I am exempt under Sec +• FINA /Over 50 to 100 Inc BY W
B&PC for this reason Over 100 0-
N
Services;Swbd,MCC& Panelboards Z
Date 0-200 Amp Under 600 V
Signature 'f!:7�,' •201 - 1000 Amp Under 600 V • ��:
Over 1000,Amp or Over 600 V
❑ Exemption fortReg Maint Elect-
�.
SINGLE FAMILY-- Temp Power Pole&Appurtenances ' 3
HOME OWNLR-BUILDER DECLARATION Sign with•One Branch Circuit i
I hereby affirm that,I am exempt from the Contractor's License Law ACC a'
for the following reason(Section 7031 5,Business and I?rofessions Additional Sign Branch Circuits
Code)
.S" 725.20
E] 1,as owner of the property;will•do'the work and the structure Misc-Conduits-&Conductors '
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 1' ITEMS
'
and Professions Code) ® • TRAL 25-20
CONSTRUCTION LENDING AGENCY ' CHECK - 25 20 ,
'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) ;'•. CHANIGE "■0I3
Civ C)
T r PLAN CHECKING FEE -
Lender's Name
PERMIT ISSUING FEE t_. 1301,
00OP-OW1 7/ 3/90
• •Lender's Addressd
Y 1634 1 AM 8:51
1 certify that I have read this application and,state that the above TOTALFEE - "
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
property for inspection purposes ' t -
SEE REVERSE FOR EXPLANATORY LANGUAGE .
-714
Signature of PerrAitteb Date