HomeMy Public PortalAbout9073 ACASO DR_Electrical_6/21/1982_fixtures and appliances WORKERS'COMPENSATIONDECLARATION ``CE8 6G (280) APPLICATION FOR ELECTRICAL PERMIT _
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I hereby affirm that I have a certificate of consent to self - -COUNTY OF LOS ANGELES � �� � BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or 1 ' '
r `a certified copy_thereof Sec 3800,Lab C) `
6te-m�4 {- -FOR APPLICANT TO FILL IN L,JOB
Po icy No Company ADDRESS Q
- New Residential Bldgs &Pools EACH NO FEE
Certified copy is hereby furnished / f 7� 1 &2-Famlly,Sq Ft $ — $ LOCALITY '-e e-iMultiG.
Certified co'py is filed with the county building inspection Residential
wi Ft Po r CROSS STS _ - r
department Residential Swimming Pools OWNER OR
' ��jjqq,,yy��q� p/� QJ�� G�7G'�P�� i FIRM NAME , 'UJ1
Dated Apphcantl3�i{ Z / "
'' II Outlets Rec LLlght_Sw l�J ADORESS�
First 20
,•CERTIFICATE OI'EXEMPTION FROM,WORKERS' Total No �� Additional CITY - fVL Tel Norte/ ,
i COMPENSATION INSURANCE
` _ �F PLAN CHECK a
- APPLICANT CL
(This section need not be�completed if the work involved �a U
Lighting Fixtures
by •the, permtt'ts for one hundred dollars ($100) or less) ( S' Additional
� ADDRESS t
, - Total No L.. ddio1
I,certify that in the performance of the work for which this ( CITY ._ , ,Tel'No O.
permit is issued, I shall not em to an person in an manner Fixed Appliances Not Over'1 HP
P P, Y Y P Y / PERMIT i V
so as to become subject to the Workers' Compensation Laws . Range_Heater D W � APPLICANT PG A '-~Q� C W
1 _ ' 1 . Oven Dryer_W M �. ( ADDRESS ! ZZ. �t�f J J N
Date Applicant -Top FAU`_W H t _ Z'
Hood Fan Other_ CITY I Jr rTel No
NOTICE TO APPLICANT If, after making this Certificate of Dlsp Room AIS Cond �d ICENSE OR i
Exemption, you should become subject to the Workers' REG NUMBER aFlrtl Class "f o
Compensatiori provisions of the Labor Code;you must'forth- Power Apparatus&Large Appliances r DISTRICT NO P SED BY
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP,KW,KVA,or KVAR 1
i -
Up to 1 Incl ,
Over 1 to 10 Incl FINALDATE
LICENSED CONTRACTORS DECLARATION VALIDATIO
Over 10'to 50 Incl
r , - NAL
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY
t ,
ness and Professions Code, and my license is ini'full force and F '
effect r 1 ,
Services
License Number-32 7 094- I Lic Class Z,r 0-200 Amp Under 600 V r '
! rA¢c4 ¢Gf 201-1000 Amp Under 600 V
Contracto Date / Z 6� Over 1000 Amp or Over 600 V 1
HOME OWNER-BUILDER DECLARATION Temp Power Pole&Appurtenances• r `
I thereby affirm that .I am exempt from the Cont'ractor's
Sign with One Branch Circuit
License Law for,the,following reason (Section 7031 5, Busi- Additional Sign,Branch Circuits „ 2 4-�I.t6 A '
ness and Professrons,Code) - 1
4
J. Mlsc Conduits(&Conductors ; - $�.e e a 6 • 2
0 1, as(owner of the property, will do the work and the Other(See Complete Fee Schedule)— i
structure is not),intended or,offered for sale (Section 1 1, - 2'",24 7 0
7044, Business and Professions Code) '
CONSTRUCTION LENDING AGENCY , o's fo 2(( 7,,Q v
I hereby affirm that there is a construction lending agency r ` ' P
for the performance of the work for which this permit is PERMIT FEE ' (Sub-Total) 12.23-81 i
issued(Sec 3097,Civ C)
Lender's Name PLAN CHECKING FEE- (One-Fourth Permit Fee) r
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Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE 71 � T
above information is correct I agree to comply with all County °, 1
ordinances and State laws regulating Electrical wiring, and,
hereby authorize representatives of this County to enter upon
the abytve-merittoned pro er for sp t:on purposes I
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature ofTermittee Date r