HomeMy Public PortalAbout9073 ACASO DR_Electrical_12/18/1981_furnance WORKER S'COMPENSATIONDECLARATION 63
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I 06G f2 80) + APPLICATION FOR ELECTRICAL �PER-MIT
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I hereby affirm that I have a certificate of consent to self , COUNTY-OF LOS ANGELES`r _-7 L BUILDING,AND SAFETY
insure,,or a certificate of Workers'Compensation Insurance,or /;! ;, % ,
a certified opy thereof(Sec 3800,Lab ) o JI `^
FOR APPLICANT`TO FILL IN JOB '1
Policy No' Company EACH, NO' ', FEE I ADDRESS, U ./ 4 '�
t r New Residential Bldgs &Pools i
❑ Ce fled copy is`hereby furnished / 1 &2-Family,Sq',Ft $ — $ �' LOCALITY
I Multi family Sq Ft `� ` — 1 NEAREST t
Certified copy is Bled with the county building inspection - i ��� t CROSS ST 11'��131s
"Residential`Swimming Pools _
' department- "� � - , � OWNER OR //�� �,
FIRM NAME, LS W_ l p La
Date �A licant {�LC�.(�eA r�'LJ<G 0 � w � , `« _ + f
pp 'r Outlets Rec-_Liglft SW ` MAIL r
• ' , `r First 20- j ADDRESS • ,
rCERTIFICATE_OF EXEMPTION FROM WORKERS' ' '
Total No Additional CITY+ el No
COMPENSATION INSURANCE - i ` = �� r a }
/ - PLAN CHECK +. C
APPLICANT, O
(This section need not be completed if the work involved - U
by the permit is for one hundred'dollars,($100) or less) L'ighting-Fixtures f First 20 ' ADDRESS
11 1 Additional O`
_ ,. . Total No r
I certify that in the performance of the wo' k,for which this + +. CITY �TeI,No
Fixed`Appliances Not Over 1 HP + V
permit is issued, I shall not employ any person in any manner e J , PERMIT "I" t `
so as tombecome subject to the Workers' Compensation Laws Range—,Heater—DW- + APPLICANT e-A F_cf(� i1Z C d
r
r r + Oven _ Dryer W M'� s y + ADDRESS t �7 � ''r1rAY I/V , - a Z
Date Applicant \
+' � a /
Top _;FRAU _W H
� _ - _ � -
+ < l r I Y h g, C( '}J eo
_ r^ Hood _ Fan _Other_ 1 � CIT1�+Z� ✓� l N ,gJ4,
NOTICE TO APPLICANT If, after making this Certificate of Disp Room Air`Cond LICENSE OR ' ° !r
Exem tion, L 1 , - REG NUMBER Z'170. &,Class
p you should become subject to the Workers' C � C-10
`Compensation provisions of the Labor Code, you must forthPower Apparatus& Large Appliances• 6. DISTRICTkNO� , PROCE SED BYE
BY-
with comply %with such provisions or this permit shall be f
deemed1revoked r Size&Type HP,KW,KVA,or KVAR r ,
Up/to 1 Incl I -
i r FINAL
LICENSED CONTRACTORS DECLARATION a Over 1 to 10 Incl DATE /21� �VALI DATION ,
Over 10 to 50 Incl ( +
` I hereby affirm that I am licensed under provisions of Chapter r Over 50 to 100 Inc FINAL
9 (commencing with Section,7000)of Division 3 of the Busi- Over 100 ' BY ' � '�'i"P •' r ''
ness,and Professions Code,,and'my license'is in full force'and
effect - i Services
0-200 Amp Under 600 V
License Number LLic Class G �
qq�� I T + ( _201-1000 Amp Under 600 V !
Contractors'e5i,ettA, +£'� Date Wap - Over 1000 Amp or Over 600 V + r �4
'. HOMErOWNER BUILDER DECLARATION( Temp Power Pole&Appuftenances
�I 'hereby affirm that I am exempt from the Contractor's Sign with One'Branch Circuit
Additional Sin Branch Circuits
License Law for the following reason (Section 7031 5, Busi- _ g _ i r I
ness and Professions Code) + J t %
i Misc Conduits&Conductors
❑`[; as owner of the property,-will do,the work and'the Other(See Complete-Fee Schedule)—,
' r T ` " #1 a`o+e e e 2 v
structure is not-intended or offered f65,sale((Section _ I + 4
• 7044,Business and Professions Code)
( CONSTRUCTION LENDING AGENCY _ r r + L` P -'-' 2 3,5 O
I hereby affirm thatIthere is a construction lending agency + `' ' e e'e 23'5 0z
for,the performance'of the work for which this permit,is -(Sub-Total)
PERMIT FEE f _ r i '_ U -�
issued(Sec 3097,Civ C) , i x•2'1 5t_'81
Lender's Name PLAN CHECKING FEE VOne-Fourth Permit,
Feel
Lender's,Address 'PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE " i' �� J u I
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
thea ove-mentioned property for inspection purposes 1
f wA SEE REVERSE FOR EXPLANATORY LANGUAGE 1
Signat of Perms tee ' r ate - , • r 1