HomeMy Public PortalAbout9939 BROADWAY_Electrical__ DEC
TION
76A66
WORKERS'that
t I have
a certificate
cafe of corse CE-806 ,D,B, APPLICATION FOR ELECTRICAL PERMIT
I berebq affirm that I have a certificate of consent to self CE-8066
Insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified co y thereof (Sec. 3800, Lab._C.)
❑ K
Poli Company FOR APPLICANT TO FILL IN JOB p �j �J •_ /J
Certified copy is hereby furnished.
New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS
INCertified copy is filed with the county building inspec- I & 2-Family;Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — 'NEAREST -
J��.-, Residential Swimming Pools CROSS ST. M
Date�lG�L'1ZZ Applicant OWNER OR
FIRM NAME ✓hl�7t=L�"'k',.
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light
-MAIL
COMPENSATION INSURANCE $w._
First 20
ADDRESS Fyr��C7�E-tryC"
(This section need not be completed if the work involved by Total No. r CITY �^ /, Tel. No.
the permit is for one hundred dollars ($100)or less.) Additional L—
certify that in the performance of the work for which this PLAN CHECKAPPLICANT
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 r ADDRESS
Total No. Additional
Applicant CITY Tel. No.
Date A
PP Fixed Appliances Not Over i HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT j9
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 5 4/
with comply with such provisions or this permit shall be Top _ FAU —W.H. — CITY��� TeL No.
deemed revoked. Hood — Fan — Other—
LICENSED CONTRACTORS DECLARATION LICENSE R 7y �Q _
hereby affirm that I am licensed under provisions of Chapter 9 Disp: — Room Air Cond: REG. NUMBER Clas .
(commencing with Section 7000) of Division 3 of the Business power Apparatus& Large Appliances DISTRICT NO. _ PROCE E BY Y
and Professions Code,and m license is in full force and effect.
fJy /7 � �'� Size 8 Type HP, KW, KVA, or KVAR Jc 0
License Number > 7Y�'sc7 Lic. Classes U to 1 Incl. FINAL IJ
C nyraco /C`}// r-'� Date &7j—SS Over I to 10 Incl. DATE /) 'Q VAU ION 09
Over 10 to 50 Incl FIN v U F
❑ I am exempt under Sec. Over 50 to 100 Inc. - BV d
B.&P.C. for this reason Over 100 Z
Services, Swbd., MCC 8 Panelboards ,
Date: '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. ;22223A .
SINGLE.FAMILY Temp. Power Pole &Appurtenances # e e o e e 2HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
1 hereby affirm that I am exempt from the Contractor's License e Additional Sign Branch Circuits ) o 2550-
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ 1, as owner of the property, will do the work and the Misc. Conduits &Conductors e o e p 5 5 0
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— ,
7044, Business and Professions Code).
0607-85
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a 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
Lender's Name 46 5-6
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE s
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 property for inspection purposes. SEE REVERSE FOR EXPLANATORYLANGUAGE
Sign Lure o pe,Pmittee ' Date