HomeMy Public PortalAbout9556 BROADWAY_Electrical__ . Ib Wm that I •COMPENSATION DECLARATION 76-663 10/81 .APPLICATION FOR -ELECTRICAL PERMIT ,
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I hereby affirm that ( have-a,certificate of consent to self insure; ' - r or a,certificate of Workers' Compensation Insurance;or a certified COUNTY OF LOS ANGELES. BUILDING AND SAFETY
copy thereof (Sec.3800,Lab.'C.)
Policy No. Company "' .•''. _ FOR APPLICANT TOFILL IN', .. ,' -'' �; - -JOB -
,ADORESS
❑ Certified copy is nereby�furnished. - New Resitlential Bldgs.&Pools - EACH NO. FEE, ..
❑ Certified copy is,filed!with the county building inspection 1 &2-Family, Sq.FL. $ — SLOCALIT�Y,
department. < . - ..Multi-family Sq Ft •CPOSSSST41—
Date °Y^` -
ResidentialFSwimmirig Pools .OWNER OR%t
n
" 'Applicant •' ' • NAME
CERTIFICATE'OF'EXEMPTION FROM WORKERS' _j Z'L / / —
Outlets:Rec Light w t •`' MAIL
• COMPENSATION INSURANCE 'sf7 ADDRESS '
-p ( y First 20 - — -
(This section need-not be coin leted if the work involved b the GITY, Tel.No �y `
permit Is for one hundred dollars $100) or less:)., Total No. Additional ' N+11.1�(0 ,•
'PIAN'CHECK -
I,certify,that in the-performance of the,work for which.this-permit - ;APPDCANT,- '
is.issued, I.shalLnot employ. any person in any manner so-as to - "• •� -
become subject•to;the Workers.Compensation Laws. • Lighting Fixtures. First 20- +'ADDRESS •tq ,
1. e -
Additional _ Q
Total No. TeL No.
CITY
Date .Applicant . Fixed Appliances NoI .. _.:.
NOTICE TO APPLICANT.•ylf, after, making. this ,Certificate of - t Over 1 HP PERMIT
Exemption,you should become subject to,the.Workers I Compensation. Range Heater_ D.W. _ . ' APPLICANT
provisions of the labor Code, you must forthwith comply with such Oven - Dryer-_ WM._ - � ADDRESS
provisions or this permit shall he deemed revoked.
Top ��FAU ; ,W.H. - - -
LICENSED CONTRACTORS DECLARATION
, � Hood � Fan Other .'TeISNo.
b,hereby afhrm,that'[ am'licensed un der provisions of Chapter 9 D Q Q LICENSE.OR
(commencing:with Section 7000)'df Division 3 of [he'Business:and Disp. .,�. Room Air Cond. REG:NUMBER "•- Class.
Professions COde;•and my-license,is infull force and effect: DISTRICT NO, P CESSED BY
.'Power Apparatus-& Large,Appliances -
Size& Type HP. VA;or KVAR •- - .� - a
License.'Number Lic.Class /4f�-N/(K1, - - •^ O
UP"too ncl r_ . FINAL U
Over'l to 10 Incl.
DATE �
Contractor"" - - Date - - I - - - _ VALIDATION
Over 10'to50 Incl. FINAL i V-
❑, am exempt under Sec. Over 50 to 100 Inc.
BY -, - .._ .. W
B.BP.C. for.this reason Over 100 ' N'
. Sa.vices, it M C 'Panelboards
Date: 600V - ' •r -- -� Z
D.. .
Signature 201--•1000 Amp.Under 600 V r •• -- -- - '
- - -Over 1000 Amp. or Over 600•V
Exemption for Reg.Maint.Elect.
" SINGLFAMILY• ' T
Eemp.Power Pole&.Appurtenances
:HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit, t YnyyT.p v-
I hereby affirm that I am exempt from--the Contractor's License Law -for the following reason (Section 7031,.5,Business and Professions Atlditional.Sign Branch Circuits • nn•a __; -303
.70
.Code): 1 ITEMS
....
Misc�Conduits&•Conductors — - r
❑' as ownerded,or offered
or do e (Sectio
and tfie structure .- r TOTAL., 303.7�
is not intended,or offered for sale (Section 7044, Business Other(See.Complete Fee Schedule)
and Professions Cade).
CHECK 303.70
CONSTRUCTION LENDING'AGENCV
� _ . .
XNANGE
Thereby'affirm that there is,a construction lending agency for:the 00
- - ^' `
Performance of the work for which this:'permit is issued(Sec.3097„ -PERMIT FEE- t - -(Sub-T6call- D
Civ.C.).
• PLAN.CHECKING FEE _ 0000-0001 _ " j 196
Lender's Name - •.' - ` 1
•. . ..PERMIT ISSUING.FEE. - b _,. 1. 12:10
Lender's Address' - - - -
I certify that I have read this application and state that the above TOTAL FEE - 3•
'information is•correct. I agree to comply with all County ordinances. ., -.
76
and State'laws regulating Electrical wiring, and hereby authorize % - -
representatives of this County to enter upon the above-mentioned_ '
property for inspection purposes.
-------�� t ,. SEE.REVERSEFOR EXPLANATORY LANGUAGE. .. •. ., _ _ "" '_ _ ,. ,.
ature of Perrilittee ae
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