HomeMy Public PortalAbout9441 LAS TUNAS DR_Electrical_12/20/1988_Subway_outlets and light fixtures r WORKERS' COMPENSATION DECLARATION ,: 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT 3I
--t' ereby aH?m that I have a certificate of,consent to self'insure, CE-806G .
or a cWtificate of Workers'.Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)a.)
;Policy No.d!ll yC �T""�"^ IeA'�a �f _
C n FOR�t-L�APPLICANT T FILL.IN JOB
Q Certified copy is hereby furnished. POtRS EACH: NO.. FEE' ADDRESS
1'& 2 Family, Sq:.Ft.
-!Certified copy is file8" with the county building inspection. _ rr
$ $ LO
department. �M[ul]ti-family Sq.Ft.
• ', -
NEAREST. `
CROSS ST.
Date plicant �f idential Swimming Pools' OWNER OR
t' _ -FIRM NAME
CERTIFICATE OF EXEMPTION.FROM WORKERS' �t MAIL
COMPENSATION INSURANCE. Outlets:Rec Light First 20 -_ ADDRESS-_p+Z t�15 v .
(This section need not be completed if'the work.involved by the CITY Tel.No:
permit is for.lone hundred dollars($100)or less.) Total No. Additional
'CHECK
I certify,that in the performance of the work for which this permit APPUCn .
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 ADDRESS
Additional
Total No. Cl
Date Applicant s
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO.APPLICANT: df, after making this Certificate_ of �.
Ran a Heater— D.W. APPLICANT`;%�'
Exemption,you should become subject 3o the Workers Compensation Range— . .. - - ,
provisions of the Labor Code, you must forthwith comply with such a py�; ven1 Dryer — W.M. ADDRESS,
provisions or this permit shall be deemed revoked. Top — FAU. —. W.H..T CITY
LICENSED CONTRACTORS DECLARATION Hood — Fan Other— /t Tel.No: -L(
I ,hereby_ affirm•that' I am licensed under,provisions of Chapter 9 V (CENSE OR , f
Dispr—,Room Air Cond. =. REG.NUMBER. • . Class.
(commencing with Section 7000)of Division,3 of the Business and ,
DISTRICT No. ,�% ROCESSE Y .
Professions Cod nd y c7ess In full force and effect. power Apparatus&..Large Appliances. (,UtJ
Size& Type HP,KW,KVA,or KVAR, t Q
License-Number- lt°`�--1> Lic:Class ` Up to 1 Incl INAL V
•
Contractor`�� "X����'_v � �/_J Over T to,10 Incl. DATE
t Over 10 to 50 Incl. FIN / U
❑-- 1 am exempt under Sec. Over 50 to .100 Inc.
B.&P.C.for this reason Over 100'
BY > �' _ W
Services, Swbd.,MCC& Panelboards - Z.
. Date: 0- 200 Amp.Under 600 V �.
Signature,,, 201 - 1000 Amp.Under 600 V ..t.,
❑ Over 1000 Amp.or Over 600 V
'Exemption for Reg:Maint.Elect. {ft }
SINGLE FAMILY „ " Temp.•eower Pole & Appurtenances- o o-,o,5 9 2 S
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit -
I hereby affirm that I am exempt from the Contracto'r's License.Law 22 0 i 8 8
for the following reason(Section 7031.5, Business and Professions Additiona6Sign Branch Circuits
Code):
Misc:Conduits & Conductors
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other•(See.Complete Fee Schedule)
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 issued(Sec.3097, PERMIT FEE (Sub-Total).
Civ.C.).
PLAN CHECKING FEE.. -
Lender's Name �.
PERMIT:-ISSUING.FEE
Lender's Address
I certify that 1.have read this application and state that the above TOTAL.FEE •�
information is correct. I agree'to comply with all County ordinances
and State laws regulating .Electrical wiring, and hereby authorize
representativesof-this County to enter upon the above-mentioned
,. c` rix 1
prop�orspecfionpurposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE '.'
atur of Permittee ., Date