HomeMy Public PortalAbout9158 BROADWAY_Electrical__ WORKERS'
that
have.COMPENSATIONDECLARATION
of
76A63 10/9I APPLICATION-FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of c5iisenl to self CE-B06G
insure, or a certificate of Workers' Compensotia Insureace, COUNTY OF LOS ANGELES BUILDING AND SAFETY,
or a certified copy thereof (Sec. 380,0/, Lob. IC.,) -
fPollicy No.19 7�Companyth C7HI.AND 9 FOR APPLICANT TO FILL IN JOB
L1 jiertified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS
�y/Certified copy is filed with the county building inspec- 1 8 2-Fomily, Sq. Ft,,2703 5 — S '� LOCALITY
tion de rtmenl. - .Multi-family Sq. Ft. — NEAREST
CROSS ST.
LS Residential SwimmingPools OWNER OR
Dale _Applimn - FIRM NAME CSV 7
- CERTIFICATE OF EXEMPTION FROM WORKERS' ,,MAIL hO _ /G
Outlets' Ret_Lighl_$w._ O
.- .COMPENSATION INSURANCE'S --. ADDRESS
(This section need not be completed if the work involved by First 20 p � p.�-
the permit is for one hundred dollars ($100)or less.) Total Na. Additional CITY _ ���j)LI✓�' Tel, No.Z�,773
J certify that in the performance of the work for which this
PLAN CHECK
APPLICANT
permit is issued, (shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. ,Lighting Fixtures First 20 ADDRESS
Total No. Additional -
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT pp t /,,s
NOTICE TO APPLICANT: If, after making this Certificate of S ,c 2,IL' L/
Exemption, you should become subject to the Workers' Range—Heater—D.W.'_ APPLICANT p
Compensation provisions-of-the Lobor'Code, yod must forth- "Oven —Dryer --- W.M.= - - ADDRESS 07� - O�N.f�
with comply with .such provisions or this permit shall be Top _.FAU —W.H. —
deemed revoked. - CITYTel. N
LICENSED CONTRACTORS-DECLARATION Hood _ Fan _Other— Lau)Lau) a.Class.
Dis Room Air Cond. _ LICENSE M /5'7 `
1 hereby affirm that I am licensed under provisions of Chapter 9 p' REG. NUMBER oC -/ J Class.l:
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. P 5 BY O_
Power Apparatus 8 Large Appliances
and Professions Code,and my license is in full force and effect. O
Size 8 Type HP, KW, KVA, or KVAR' ( C.7
- License Number a.-59'1 75 tit, CIO se—ID Up to I Incl. FINAL 0
Q Over I to IO Incl. DATE 0
Contractor f �e 0 7 I J - VALIDATION V
❑ am exempt under Sec. Over 10 to 50 Incl. FINAL W
Over 50 to 100 Inc. BY
B.BP.C. for this reason - Over 100 I • . Z
Date: Services, Swbd., MCC 8 Ponelboords
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V -
❑ Over 1000 Amp. Over 600 V
Exemption for Reg. Maint. Elect.- or 2
SINGLE FAMILY Temp. Power Pole 8 Appurtenances a
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCT..
I hereby affirm that I am exempt from the Contractors License c
Low for the following reason(Section 7031.5, Business and Additional Sign,Branch Circuits 3307 148.15
Professions Code): - 1 ITEMS
- . .
as owner of the property, will do the work and the Miss. Conduits 8 Conductors
s TOTAL 148 m 1 J
structure is not intended or offered for sole (Section Other ($ee.Complete Fee Schedule)_
7044, Business and Professions Code .
) . CHECK 14.1.5
CONSTRUCTION LENDING AGENCY - - CHANGE ,00
I hereby affirm that there is aconstruction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
'(Sec 3097, Civ. C.
PLAN CHECKING FEE 0000-0001 6/22/90
Lender's Name
PERMIT ISSUING FEE - � 1420 1. AM 7%11
Lender's Address
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 regulatingElectrical wiring, and -
hereby.authorize representatives of this County tod penir(r upon _
the abo'e-menlioneert r insp ction par os s.
SEE REVERSE FOR EXPLANATORY LANGUAGE '
Z7= 50
n ur of re i Datie