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HomeMy Public PortalAbout9159 BROADWAY_Electrical__ WORKERS'have a certificate DECLARATION 76A663 I0/81 APPLICATION FOR ELECTRICAL PERMIT CE-806G I hereby affirm that I have a certificate of consent to self insure, - or a celtificate of Workers' Compensation Insurance, or a'certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy IC^reof(Se..•3800.Lzti�'.) Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is herebyfurnished. EACH NO, FEE ADDRESS New Residential Bldgs.& Pools Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ — $ LOCALITY department. Multi-family Sq.Ft. NEAREST CROSS ST. Residential Swimming Pools OWNER OR Date Applibaof FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light _L Sw. MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work involved by the First 20 permit is for one hundred dollars ($100) or less.) Total No.41Z Additional > CITY Tel.No. I certify that in the performance of the work for which this permit (^- PLAN CHECK is issued, I shall not employ any person in any manner so as to •I r 1 -'APPLICANT become subject to the Workers'Compensation Laws. Lighting Fixture First 20 I I ADDRESS Additional ` rl � Total No. CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT 1/ NOTICE TO APPLICANT: If, after making this Certificate of ! Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT J EYN provisions of the Labor Code, youmust forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY 0431 No. –I_hereby affirm that I.am licensed under provisions of Chapter 9 LICENSE OR - - - Dish. — Room Air Cond. Z Class. (commencing with Section 7000)of Division 3-o/ theBusiriess and --° - - - - -- -- - - -- - - - _- _ REG.NUMBER Professions Code,and my license is in full force and effect. DISTRICT NO. P ED B _' •�[�� Power Apparatus 8 Large Appliances Size&Type HP,KW,KVA,or KVAR \ O License NumbY -- Liu Class Up to 1 Incl. FINAL Over 1 to 10[net. DATE �'�� �! j VALIDATION 0 Contractor_\ -V-- Date–�~�' 7"/ / _ Over 10 to 50 Incl U FINAL am exempt under Sec. Over 50 to 100 Inc. By W B.&P.C.for this reason Over 100 [L Date: QI] Services,Swbd.,MCC& Panelboards D Z 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 SINGLE FAMILY Temp.Power Pole It Appurtenances HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law ' for the following reason (Section 703 1.5, Business and Professions Additional Sign Branch Circuits . - ACCT.A Code): 3307 .. 4.0.70 ElI,as owner OI the property,will do the work and the structure Misc.Conduits & Conductors is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) 1 ITEM. and Professions Code). © TOTAL . 40 . 70 CONSTRUCTION LENDING AGENCY CHECK 40.70 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHANGE .00 Civ.C.). PLAN CHECKING FEE - Lenders Name 0000-0001 7/118/90 PERMIT ISSUING FEE Lender's Address - 1871 1 AM 7:27 1 certify that I have read this application and state that the above TOTAL FEE a _ information is correct. I agree to comply with all County ordinances d and State laws regulating Electrical wiring. and hereby authorize _ representatives of this County to enter upon the above-mentioned property for i pe i n pu o s. 7 SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of.permittee Date