HomeMy Public PortalAbout9027 ACASO DR_Electrical_9/17/1986_outlets X0EKERS' COMPENSATION DECLARATION 76A663 10/81
m that 1-have a� rtificate of consent to sejf CE-806G APPLICATION FOR ELECTRICAL PERMIT
it certificate of Wai=f", Compensation 9nsuronce, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or�l 9(;V, copy thereof (Sec1R3800, Lob. C.)
v �
Policy No. lompony FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs Viols
EACH NO. FEE ADDRESS
❑ LOCALITY
1 & 2-FamiI Ft. $ — $
Certified copy is filed with the county building inspec- Y
tion department. Multi-f y Sq. Ft. — NEAREST �y
CROSS ST. v �!
R ential Swimming Pools OWNER OR ff
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' � 7 MAIL
Outlets: Rec Light Sw. -- dna
COMPENSATION INSURANCE _ � � ADDRESS
This section need not be completed if the work involved b �^ First 20
( p Y Total No. ,�V Additional CITY /(� G� Tel. No.
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this -APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 Z ADDRESS
Total No.-7 Additional `5
CITY Tel. No.
/5�6 `91,� �
Date Applicant Fixed Appliances Not Over 1 HP PERMIT 1
NOTICE TO APPLICANT: If, after making this Certificate Of APPLICANT 1G//% le-
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. CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan Other—
Dis Room Air Cond. �� LICENSE Class.
I hereby affirm that I am licensed under provisions of Chapter 9 p' REG. NUMBER
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY D-
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances V
Size &Type HP, KW, KVA, or KVAR
License Number Lic. Class Up to 1 Incl. FINAL V=
Over 1 to 10 Incl. e0 DATE
Contractor Date VALIDATION
1:1 Over 10 to 50 Incl. FINAL W
I am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100 Z_
Date: Services, Swbd., MCC & Ponelboards
0 - 200 Amp. Under 600 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 License25415
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits # 0 0 0 0
Qrofessions Code):
.
I, as owner of the property, will do the work and the Misc. Conduits &Conductors I 0 - 39,25
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ o 0 o 3 9 2 5,0
7044, Business and Professions Code). , Q 9„� 7—8 6
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 2Ad
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE (�
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 3 /q v✓
above 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
�p�t o1sefs. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature ofPermittee 41,, Date