HomeMy Public PortalAbout9018 RANCHO REAL RD_Electrical_1/5/1990_fix appliance WORKERS'COMPENSATION DECLARATIONCE806G 10/8
1
APPLICATION FOR :ELECTRICAL PERMIT
I.`hereby affirm that I have a certificate of consent to self insure, -
voter a certf'.ate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy the' (See.3800,Lab.C.) s °
Policy N / (&parry FOR APPLICANT TO FILL IN Jot ��/V n Q
❑ Certified copy:is hereby furbished. New.Residential Bldgs.!&Pools EACH NO. FEE ADDRESS 6 G
$ _ $ LOCALITY
Certified copy is filed with the.county building 1 &2-Family,Sq.Ft. _ NEAREST
departmen Multi-family Sq.Ft.
CROSS ST
ate — ® Applicant Residential Swimming Pools OWNER OR �yy�®n,
FIRM NAME �'[�y/v
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light*_Sw.— MAIL
COMPENSATION INSURANCE ADDRESS fop/&V I&Vet a Aeel
This section need not be completed if the work involved by the First 20
(. - CITY , Tel.No
permit is for one hundred dollars($'100)or less.) Total No. Additional
I certify that in the performance of the work for,which this permit PLAN CHECK . :
APPLICANT
is issued, I shall not employ any person in any manner so as t0
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CIT_Y Tel.No.
Date ApplicantFixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT� i2 �j Ne Nom.
Exemption,,you should become subject to the Workers'Compensation Range_ .Heater_ D.W. _.
provislons of the Labor Code,you must forthwith.comply'with.such Oven _ Dryer_ WM'._ ADDRESS 3 Ci A/l'�i�
provisions or this permit shall be deemed revoked. Top — FAU '� WM. _
LICENSED CONTRACTORS DECLARATION Hood _ Fan Other._ CITY r 'Tel.No 6�-31 �)
I hereby affirm that I am licensed under,provisions of Chapter 9 D.)sp. — Room Air Cond. 3 d LICENSE OR r y
(commencing with Section.7000),of Division 3 of the Business and REG:NUMBER v 73J C14C >(J
Professions Code,an&my-license is in full force and affect. DISTRICT NO. PR D BY
Power Apparatus&Large Appliances
) �� r p
Size&Type HP,KW,KVA,or.KVAR (�
License Number �l��3 73 Lic.Class C �J Up to 1 Incl. FINAL
Contractor �L �e �� � Dat �'y ��� ®Y Over 1 to 10 Incl. DATE
,. VALIDATION 0
Over 10 to 501ncl. `!
❑ I am.exempt under Sec. Over 50 to 100 Inc. gy , v r
W
BAP.C.for this reason Over 100
Services,Swbd.,MCC&Panelboards ► *; I D . lW!" }
Date: 0-200 Amp..Under 600 V,
Signature 201 - 1000 Amp.Under 600 V
g P
❑ Over 1000 Arnp.,or Over.600 V
'Exemption for-Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER:BUILDER DECLARATION ' JL
Sign with One Branch.Circuit ACCT o v
,.. I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits
Code): ��
for the following reason(Section 7031.5,Business and Professions 5�07 21.00
Misc.Conduits&Conductors 1 ITEMS
❑ 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) _ Poo. CHECK
and Professions•Code).
CONSTRUCTION LENDING AGENCY
CHECK 21.130
I hereby affirm that there is a construction lending agency for the CHANGE ,a[I
performance of the work for which.this permit is issued(Sec.3097, PERMIT FEE (Sub Total)
Civ.C.).-
PLAN CHECKING FEEQa�_��01
Lender's.Name
'
Lender's Address PERMIT ISSUING FEE �® �
.8069 1 AM' 9016
1 certify that I 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
representatives of this County to enter upon the above-mentioned
props for i, pection�.pu�rpo p SEE.REVERSE FOR EXPLANATORY LANGUAGE
i
Sig ture o Permittee Date
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