HomeMy Public PortalAbout9158,9152 BROADWAY_Electrical__ WORKERS' COMPENSATION DECLARATION md-8
76A653 ,10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have o certificate, to self 'CI'B06G
insure, or a certificate of Workers' Compensation Ipsurance_ COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified
cOjy'thereof (Sec. 3800, Lab. 'C/.)I I,�J t�
Policy No.I`77DI Company r�,[�E7 - T'`L`S FOR APPLICANT TO FILL IN ADDRESS
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE 9 L2
Certified copy is filed with the county building inspec. 18 2-Family, Sq. Ft..M:3 _ $ LOCALITY
NEAREST
Ilan epa tment. Multi-family $q. FL CROS ST. '
C Residential Swimming Pools OWNER OR _
Dote Applica FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec`LightSw._ MAIL �' n�� C
COMPENSATION INSURANCE First 20 ADDRESS L,�7,2 d
r
(This section need not be completed if the work involved by Total No. - Tel. No. = 1
Additional - _ 3 �:Ac
the permit is for one hundred dollars ($100)or less.) PLAN CHECK r
I certify that in the performance of the work for which this APPLICANT
permit 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
Total No. Additional CITY Tel. No.
Date Applicant Fixed Appliances Not Over I HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANTI.7
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._ ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY Tel. No.
Hood Fan _ Other—
LICENSED CONTRACTORS DECLARATION - LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER d Class.C'0 Y
(commencing with Section 7000) of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. - PR C BY d'
and Professions Code, and my license is in full force and effect. U
�jQ UP to 1 Incl
Size 8 Type HP, KW, KVA, or KVAR' .I
License Number d0,11 Z_ Lic. Classe4o FINAL
.
Over I to 10 Incl... DATE `I� VALIDATION I—'
Controcto Rw%"Le' ye nate Over 10 to 50 Incl. V
1:1FINAL / / Wa.
I am exempt under Sec. Over 50 to 100 Inc. BY �
B.BP.C. for this reason Over 100 z
Date:
Services, Swbd., MCC 8 Ponelboards D t'
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
s
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION ACCT.4
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit c
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 3307 14+8.15
Professions Code): 1 ITEMS
._
I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ VITAL 143 - 15
7044, Business and Professions Code). D CHECK 148.15
CONSTRUCTION LENDING AGENCY CHANGE .00
I hereby affirm that there is o construction 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 31419 1 AM'7:10
PERMIT ISSUING FEE 00
Lender's Add•ress
I certify that I hove read this application and state that the TOTAL FEE !6
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize represe tatives is County to enter upon
ve-mentioned pr ty f r s/p/ecY;orposes �/q SEE REVERSE FOR EXPLANATORY LANGUAGE
r M�°'VG-� !d
gn lure of Permittee Dote /