HomeMy Public PortalAbout9415 BLACKLEY ST_Electrical__ L ' • \
WORKERS'COMPENSATIONDECLA�P CE�A5GY28Q) ; APPLICATION FOR ELECTRICAL PERMIT
_,1' . - 1
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 thereo�'ff(Sec 3800, Lab Ca)
Gf(o-�7C`l `' �� 5 �� FOR APPLICANT TO FILL IN 3pgjI
Policy No / Company EACH NO FEE ADDRESS
❑ New Residential Bldgs &Pools 1
Certified copy is hereby furnished , 1 &2-Family,Sq Ft $ — $ LOCALITY "T� P�S L(
Multi-family Sq Ft NEAREST
Certified copy is filed with the county building inspection CROSS ST
dep tin nt Residential Swimming Pools OWNER OR d� /�
- ti FIRM NAME �tCL.tfip /r
Date- s���--�— Applicant ��^-^ � �/w Outlets Rec LightSw ADDRESS l rJ
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No 3 AdditionalCITYr�p Tel No a
COMPENSATION INSURANCE
PLAN CHECK
(This section need not be completed if the work involved APPLICANT /&_Tr -4/a.S7-'f�3'��'-
/C 1TO OU
cc
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS eQe7 4 5
Additional
I certify that in the performance of the work for which this Fixedal No Appliances Not Over 1 HP CITY Lem L.v(/� Tel No S9C����? O'
permit is issued, I shall not employ any person in any manner - PERMIT 0
,so as to become subject to the Workers' Compensation Laws Range_ Heater_D W r APPLICANT p,
Oven Dryer'_W M ADDRESS to
a Z
Date - Applicant Top FAU -W H
Hood — Fan _Other_ CITY Tel No
NOTICE TO APPLICANT If,,after making this Certificate of Dis _ Room Air Cond_ LICENSE OR aa
Exemption, you should become subject to the Workers' p REG NOMBER39�C>6� Class -/
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO PROCES ED BY
with comply with such provisions or,this permit shall be Size&Type HP, KW, KVA,or KVAR
deemed revoked ��
- Up to 1 Incl '
FINAL
Over 1 to 10 Incl
DATE VALIDATION
LICENSED CONTRACTORS DECLARATION
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 i
ness and Professions Code, and my license is in full force and
effect Q Services ,
393bco }Br-� 0 0 Amp Under_60 `V
License Number Lic Class
&;CIT-"A _ 201-1000 Amp Under 600 V
Contractor PsA'T�0 Date' 9 Over 1000 Amp or Over 600 V
HOME OWNER-BUILDER DECLARA ION Temp Power Pole&Appurtenances
Sign with One Branch Circuit �09 4 Jr 0,9 A
I hereby affirm that I am exempt from the Contractor's Additional Sign Branch Circuitst
_
License Law for the following reason (Section 7031 5, Busi- # 0 0 0 0 o 2
ness and Professions Code) ; I , .
Misc Conduits&Conductors o '0 27,75
I, 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 i oro 0 27-752:
'
7044, Business and Professions Code)
CONSTRUCTION LENDING AGENCY 09,28-84
I hereby affirm that there is a construction lending agency
a
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec 3097,Civ C)
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address -
_ PERMIT ISSUING FEE
I certify that I have read this application and state,that the TOTAL FEE G i'
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 pro ty for inspection purpose SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dat i