HomeMy Public PortalAbout10684 ARROWOOD ST_Electrical_8/29/1980_light outlets and switch ` W('JRKERS'COMPENSATION DECLARATION CE 806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
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
a certified copy thereof(Sec. 3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB �V vnW®Dw, T
Policy No. Company EACH NO. FEE ADDRESS 1.
New Residential Bldgs.&Pools
F1 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITYe r
❑ Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection' CROSS ST a
department. Residential Swimming Pools OWNER OR //��
FIRM NAME a e � 41W -h
Date Applicant Outlets: Rec.^Light Sw. `D AIL
First 20 ADDRESS 509ZrXi9_ A-9 as ,
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No. }
COMPENSATION INSURANCE PLAN CHECK d
(This section need not be completed if the work involved APPLICANT O
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS U
Additional
Total No. 3 3
1 certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. O
permit is issued, I shall not employ any person in any manner , PERMIT �A� v- 0
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT Y� e— LU
Oven _ Dryer_W.M. ADDRESS U)
Top _ FAU _W.H. Z
Hood Fan
Date Applicant _Other CITY el No.
_ -
NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond-_ LICENSE OR
Exemption, you should become subject to the Workers' REG. NUM R Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCESSED Y
with comply with such.provisions or this permit shall be Size&Type HP,K , KVA,or KVAR
Up t
deemed revoked. W
o 1 Incl.
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE VALIDATION
Over 10 to 50 Incl.
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
ness and Professions Code, and my license is in full force and
effect. Services
0-200 Amp. Under 600 V
License Number Lic.Class
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole& Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits&Conductors
1, as owner of the property, will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.). 1 9 k7 A
Lender's Name
PLAN CHECKING FEE (One-Fourth Permit Feel ° r, o 0 0 2
T1
Lender's Address PERMIT ISSUING FEE
2 - 120G
I certify that I have read this application and state that the TOTAL FEE
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 0 €:2 9"C 0
the above-mentioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE '
C
Signature of Permittee Date