HomeMy Public PortalAbout9023 JAYLEE DR_Electrical_11/14/1994_service panel (�(�p �a pp (� �a (� 2-8(D- 1
WORKER'S I have
a certificate
DECLARATION to 76A669 DPW(12-9t) APPLL,I�lA�� N FOR ELEC�•I(' ICAC PERNT _`q 0
76A663 LL u�/u '
I here�h�,y affirm'That I have a certificate of consent to self insure,
or a ,E tificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Seca 3800 Lab..C.) .
Policy NO. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby fumish'ed. New Residential Bldgs.&Pools NO. $ EACH $ FEE LOCALITY
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST , t
department. Multi-family Sq.Ft. CROSS ST. S vt
Date Applicant' Residential Swimming Pools MASE
.PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rea_Light SW. OWNER OR
COMPENSATION INSURANCE / LFIRM NAME
First 20 MAIL '
(This section need not be completed it the work involved by the i ADDRESS C�3 � �sC. �;r�l�
Total No. Additional /r1
permit is for one hundred dollars($100)or less.)'
I certify.that in the performance of the work for which this permit CITY yds t oY:�h�L.l Tel.No.
Is issued, I shall not employ any-person in any manner so as t0 PLAN CHECK
become;subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
DateApplicant
NOTICE-TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY Tel.No.
Exemption,youu should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith I with such PERMIT
y comply y Power Apparatus.&Large Appliances APPLICANT (�/✓t•!h
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby-affirm that I am'licensecl under provisions of Chapter 9 Over 3 to 10 Incl. /
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. /'
LICENSE }
- Over 50 t0 100 Incl. � REG.NUMBB ER Class. a
Over 100 - DISTRICT NO. Pggq���ESSED BY .O
License Number Lic.Class .`-
i
Services,Swbd & anelboards a/7
0=399 Amp.Under 600 V -_;;o/ FINAL O
Contractor Date._• - DATE .. ..
❑
I am exempt under Sec. 400-1000 Amp.Under 600 V ✓' 441 VALIDATION V
Over 1000 Amp.or Over 600 V FINAL . . d
-B.&P.C.for this reason BRANCH CIRCUIT.FEES BY
Date: 15A,or 20A,120V,Lighting or Recepf. Z_
1 To 10 Branch Circuits
Signature .11 To 40 Branch Circuits /
❑ 41 Or More.Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION —
I hereby affirm that I am exempt from the Contractor's License Law .Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits TT•m -
Code): 1 t
I, as owner of the'property, will do the work and the structure Misc.Conduits&Conductors j 5_'', 3
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) D
and Professions Code). '•_• 's"f _ .=ti
CONSTRUCTION LENDING AGENCY '^
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) _
Civ. C.)_ fYt i4 ssY_,if i_f y
PLAN CHECKING FEE -
Lender's Name
PERMIT ISSUING FEE �9
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE ,
that the 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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
11P 511"
SIGNATURE OF PERMITTEE DATE