HomeMy Public PortalAbout5827 ENCINITA AVE_Electrical__ TION
WORKERS'CI hove ATIONDteof once t71!Vi voPwsiez APPLICATION FOR (ELECTRICAL PERMIT
O
2a(*1
I hereby affirm that I hove a certificate of consent to self .cE.eosc
insure, or a certificate of Workers' Compensation Insurance, - COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. 'I�1l!p bT Company _rAIKAdONr. FOR APPLICANT TO FILL IN. JOB
❑Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS
Certified co is filed with the countbuilding inspec- 1 8 2-Family, S Ft. 1 1 7 $ — $ LOCALITY
PY Y 9 P y' q' T�
tion deportment. Multi-family Sq. Ft. NEAREST
0 Residential Swimming Pools CROSS S
Dafen Applicant //7AI f-Ils:A LfY OR I
t RM NAME - -
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec—Lig ht_Sw._ MALL
COMPENSATION INSURANCE First 20' ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITY` Tel. No.
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
1 certify that in the performance of the work for which this APPLICANT
permit is issued, l shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Total Na. CITY Tel. No.
Dale 3 'D Applicant afte mak i-lhis LLA /f-f Fixed Appliances Not Over I HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION
Exemption, you should become subject to the Workers' Range— Healer—D.W. V.
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. 4
deemed revoked. Hood — Fan —Other— CITY A C- el. No.,�p _7&
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Class. G-
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. P 5 ED BY Y
and Professions Code,and my license is in full force and effect, d
Size 8 Type HP, KW, KVA, or KVAR1 O
License Number.r>f-r[f'� Lic. Class G-/L1 Up to I Incl. FINAL V C..)
Over I to 10 Ind. DATE f/ VALIDATION
Contractor ' Date.--I �V
F] Over 10 to 50 Incl. FINAL
am exempt under Sec. Over 50 to 100 Inc. BY LU
.11
B.BP.C. for this_reason Over 100 d
Services, Swbd., MCC 8 Panelboards D V)
Date. 1X1 0- 200 Amp. Under 6V Z
Signature I-M LILUA Ly61 201 - 1000 Amp. Under 600 V
OExemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY
Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION a
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit ALICT.s-
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 3307 93.Z.15
Professions Code):
Misc. Conduits 8 Conductors
f 1 ITEMS.
I, as owner of the property, will o the work and the 5
structure isnot intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ D TOTAL 9� ® i•�
Business and Professions Code). CHECK, 98.P5
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for CHANGE .00
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE 131)010-13131)1 7/14/90
Lender's Name
PERMIT ISSUING FEE 3 8936 i AN. 3%1'i
Lender's Address
I certify that I have read this opplicotion.and state that the TOTAL FEE
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 EXPLANATORY LANGUAGE
Y
Signature of Permittee D to - C),