HomeMy Public PortalAbout10819 FREER ST_Electrical__ r) .11r-.a*
WORKERS' ave a ceSAfJN of con RATION CEA806G '°'6tAPPLICATI®N E®R ELECTRICAL PERMIT
hereby affirm that I have a certificate of consent to self insure,certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3 00,1_ab. C.)
Policy NO. Company —.— '"� FOR APPLICANT TO FILL IN JOB y�
❑ EACH NO.. FEE ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.& P of LOCALITY
Certified copy is filed with the county building inspection 1 & 2-Family, Sq.Ft. $ — $
department. Multi-family Sq.Ft. — NEAREST
Residential Swimming Pools CROSS
Date OWNER O Applicant OR
/ FIRNAME Wo
J
M
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL
COMPENSATION INSURANCE ADDRESS
This section need not be completed if the work involved First 20
( b P Y the CIT
K Tel.No. _/
permit.is for one hundred dollars($100)or less.) Total No. Additional.
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
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 ADDRESS
Total No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HPPERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT. vy G
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer W.M._ ADDRESS (6O
provisions or this permit shall be deemed revoked. Top _ FAU T W.H.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9 Dis LICENSE OR
p. ROOM Air Cond. REG.NUMBE Class.e�
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PR COSED BY
p tis
/y, �� � Size& Type HP,KW,KVA,or KVAR �.�i d `A�
License Number Lic.Class�„t1�L m
Up to 1 Incl. FINAL
/��+•�l)7St /1� As/J Over 1 to 10 Incl. DATE q VALIDATION Q
Contractor � YJ l [J �L/( Date Over 10 to 50❑ Incl. ! U FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY �g
BAP.C.for this reason Over 100 .
Services, Swbd., MCC&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.
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law ;- n
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits Vit.:'•:3 =g
Code): -15
n!.I
❑ I,as owner of the property,will do ttie work and the structure Misc.Conduits &Conductors
�•^�IF
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) -';
75
and Professions Code). ®' 11-i_tTAI.. - „
CONSTRUCTION LENDING AGENCYr CHECK r f=
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)
Civ. C.). tilt st
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I 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 15? 7S
and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
ga
erty for ins ction rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ture Permittee Date