HomeMy Public PortalAbout4807 BALDWIN AVE_Electrical_02/21/1985 � I J
ERS COMPENSATION DECLARATION CE 863 to/Bt APPLICATION FOR ELECTRICAL PERMIT
pI h� that I have a certificate of consent to self CE 8066
-insure ora i if,cate of Workers Compensation Insurance COUNTY OF LOS ANGELES t a
I BUILDING AND SAFETY
or
c�ert,f�d co th eof ec 3800/,Lab C )
Policy�o6Z� ���,C pang Z J�1/ � FOR APPLICANT TO FILL IN JOB
ADDRESS �� (7
Elcertifiedcopy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
1 & 2 Family S Ft $ — $ LOCALITY Lig d
�ertified copy is filed with the county building mspec Y q —
t,on department } Multi family Sq Ft NEAREST /�
' 7i-1 �JQ ��1� Residential Swimming Pools CROSS ST A ZUS�
Date Applicant �— X �� OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw r MAIL
COMPENSATION INSURANCE ADDRESS 'f&7 WI !�
This section need not be completed if the work involved b First 20 1
( p y Total No Additional CITY E� � d,,T-\/ Tel No
the permit is for one hundred dollars ($100)or less)
PLAN CHEC
I certify that ,n the performance of the work for which this J APPLICANT }f
permit,s issued I shall not employ any person ,n any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRES
Total No Additional
CITYS I N
Date Applicant Fixed Appliances Not Over 1 HP PERMIT /
NOTICETO APPLICANT If after making this Certificate of APPLICANT
Exemption you should become subject to the Workers Range_ Heater_D W —
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M — ADDRES§46r�q &,,fg, lnF
with comply with such provisions or this permit shall be Top _ FAU —W H —
deemed revoked Hood Fan _ Other— CITY Tel No �o Z�I
LICENSED CONTRACTORS DECLARATION LICENSE OR /
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER 1210 G Class -- Q
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PRQC SED BY r
and Professions Code and my license is in full force and effect j Power Apparatus 8 Large Appliances -5 J'8 / CL
�I _ ' Size 8 Type HP KW KVA or KVAR (f O
License Number 7(D G -L L,c Class 0 Up to 1 Incl FINAL ,V
/L /� t1I cc
e / Zq gs Over 1 to l0 Incl DATE � ( � 0
Contractor tB to J VA ATION O
❑ Over 10 to 50 Incl FINAL F-
I am exempt under Sec Over 50 to 100 Inc BY 0.
B &P C for this reason Over 100 Z i
Services Swbd MCC& Panelboards ► 1 5 7 2 A
Date 0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V # 0 0 0 0 0 2❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Eject ° ° 8 5 5 0
SINGLE FAMILY Temp Power Pole & Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit o,o o 8 5.5 0 5
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and i 02-21 —85
Professions Code) I
❑ I as owner of the property will do the work and the M,sc Conduits &Conductors
structures not intended or offered for sale (Section Other (See Complete Fee Schedule)_
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 ,s issued PERMIT FEE (Sub Total)
(Sec 3097 Civ C )
>N�,/� PLAN CHECKING FEE
Lender s Name 11�L__
PERMIT ISSUING FEE V
Lender s Address r
I certify that I have read this application and state that the' TOTAL FEE sQ j
above information ,s correct I agree to comply with all County
ordi nces and State jaws regulating Electrical wiring and
reb sent t,ves of this County to enter upon
th on pro rty r ,nspe tion purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE I '
gnatu erm,ttee Date
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