HomeMy Public PortalAbout10523 DAINES DR_Electrical__ WORKERS'COMPENSATION DECLARATION 76- 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE-806806G
or a certificate of Workers' Qomgensao'�yt,'Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec-3800,Lab C) ." /�f
Policy NO Company FOR APPLICANT TO FILL IN 'S e �(,//J��
❑ Certified copy Is hereby furnished S New Residential Bldgs & Pools EACH NO FEE ADDRESS /�5r'y71 E. /LOCALITY
❑ Certified copy is filed with the county building inspection 1 & 2-Family, Sq Ft $ _ $
department Multi-family Sq Ft NEAREST,
CROSS ST
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME `!
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light _ Sw i MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20
Total No Additional r CITY Tel No
permit is for.one hundred dollars($100)or less) 1 `
I certify,that in the performance of the work for which this permit jj, _PLAN CHECK.
is issued. I shall not employ an ti 1, ,� a ( APPLICANT
p y y person in an manner so as to
Y � t
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
NOTICE TO APPLICANT If, after making this Certificate of PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ HeaterD W _ APPLICANT
_
provisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W M _ ADDRESS
provisions or this permit shall be deemed revoked Top FAU WH _
CITY Tel No
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions ofChapter 9 Disp — Room Air Cond LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and REG NUMBER Class
Professions Code,and my license is in full force and effect DISTRICT NO • PR EDB
Power Apparatus& Large Appliances
Size& Type HP,KW,KVA,or KVAR d
License Number Lic Class Up to 1 Incl FINALU
Contractor Date Over 1 to 10lncl DATE VALIDATION Q
❑ _n I ),q—)
Over 10 to 50 Incl I—
FINAL
I am exempt under Sec Over 50 to 100 Inc BY W
B&P C for this reason Over 100 n-
N
DateJL
Services,Swbd,MCC& Panelboards ® 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 & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit i
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits AC T a=
for the following reason(Section 7031 5, Business ana Professions
Code) S 1.110
® I,as owner of the property,will do the work and the structure Misc Conduits &Conductors , NS
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) I�
and Professions Code) ® TOTAL :. . Q0
CONSTRUCTION LENDING AGENCY CHECK 31.01-1
1 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 e�itj
Civ C)
PLAN CHECKING FEE
Lender's Name 1/ 5/,,1
' PERMIT ISSUING FEE _ q
Lender's Address 1673 1 AM10".5l
1 certify that I have read this application and state that the above TOTAL FEE
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 EXPLANATORY LANGUAGE
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Signatur o ermitt Date
D9 8•A 10.41 28M IIIPLll AINON FOR PJ�.lM, ,
DEPARTMENT OF AG AND SAFETYELECTRIC
COUNTY OFF LOS LOS ANGELES
WM. J. FOX CHIEF ENGINEER
a NAME DISTRICT
✓IVO., GROUP I ZONE, PERMIT NO.
U ADDRESS o�
U CITY TEL.NO. RECEIVED BY READY FOR DATE ISSUED
FIRST INSPECTION
a COUNTY
W CERT.NO. EXPIRES r'
✓ %��/`
APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY
DESCRIPTION OF WORK ADDRESS
NUMBER OF OUTLETS ON CIRCUITS LOCALITY
LOCATION BY ROOMS
NEAREST
LIGHT OUTLETS SW. PLUGS FjxT CROSS ST
CIRCUIT A B C I D I E F G H G NAME
W MAIL
!� O
..1 CITY TEL.NO.
I AM THE LEGAL POSSESSOR OF THE ABOVE LOS
ANGELES COUNTX CERTIFICATE OF QUALIFICATION.,
�I EGMUCIAN.
I AM ABO g THE{,EGAL:�/!'F TH Rf/t/ /ijo
t OPER-ffDESCRIBED
e in
OWNER.L�
C194 —VOLAS
a
z
lie
ie
�A7 �� �, ; r� o
L
NO. OF OUTLETS S D APPROVALS
NO. OF FIXTURES O� DATE INSPECTOR'S NAME
NO. OF MOTORS H.P., CONDUIT
NO. OF SIGNS , TRANS. WIRING
NO. OF,RANGES OR HEATERS FIXTURES
MISCELLANEOUS POWER
PERMIT FES UTILITYCO.NOTIFIEDtp
TOTAL FEE 5 ?
FINAL
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DB 5-A 12-43 25M APPLICATION FOR 4LT71�.�1r
DEPARTMENT of dNG AND SAFETY ELECTRIC L�
COUNTY OFF LOS LOS ANGELES
WM. J. FOX CHIEF ENGINEER
FRT
ME DISTRICT NO. GROUP ZONE PPE/hRMIT/NO.
DRESSd COUNTY
TY EL NO CEIVED BY FIR8T INSPECTIONREADY FOR DATEISSUED
NO / EXPIRES AZIl". �
APPLICANT FILL IN HEAVILY OUTLINED PORTION ONLY
DESCRIPTION OF WORK ADDRESS
NUMBER OF OUTLETS ON CIRCUITS LOCALITY J�/�1nsl
LOCATION BY ROOMS
NEAREST
LIGHT OUTLETS SW PLUGS IFIXT CROSS
CIRCUIT A B I C I D E F G IH E NAME
2 MAIL �J
3 ADDRESS
O
CITY A TEL.NO.
I AM THE LEGAL POSSESSOR OF THE ABOVE LOS
ANGELES COUNTY CERTIFICATE OF QUALIFICATION.
ELECTRICIAN.
iI 2F // I AM THE LEGAL O2117MM
P/rof A %v�`Y tel/, ABOVE /_ .4.lirOWNS
GORREMONS v
Al
J
Ti ; z
1 f 111 m, .4// o
TOTAL
NO. OF OUTLETS $ / APPROVALS
NO. OF FIXTURES Ile $ DATE INSPECTOR'S NAME
NO OF MOTORS H P. $ CONDUIT /f
NO OF SIGNS TRANS. $ WIRING 00,
NO. OF RANGES OR HEATERS $ FIXTURES 1
MISCELLANEOUS $ POWER
PERMIT FEE $ . UTILITY CO.NOTIFIED
TOTAL FEE 9 FINAL