HomeMy Public PortalAbout6059 GOLDEN WEST AVE_Electrical__ WORKER S'COMPENSATION DECLARATION CE-806 ,4PpLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES T BUILDING AND SAFETY o
insure, or a certificate of Workers'Compensation Insurance,or / / /•
a certified copy thereof(Sec 3800,Lab C)
` FOR APPLICANT TO FILL IN JOB r'
Policy Nd. Company EACH NO FEE ADDRESS �� 92-7
New Residential Bldgs &Pools '
Certified copy is hereby furnished 1 &2-Family;Sq'Ft $ — $ LOCALITY
❑ Multrfamily'Sq Ft NEAREST
Certified,copy is filed with the county building inspection CROSS ST
department 7 Residential Swimming Pools OWNER OR
( FIRM NAME
Date Applicant Outlets Rec2�ight�Sw /1 \/(� `
` First 20 v ) ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No Additional 0- 31 Tel No
COMPENSATION INSURANCE
PLAN CHECK 0-
APPLICANT
APPLICANT 0
(This section need not be completed if the work involvedLighting Fixtures First,20 ADDRESS U
by the permit is for,one hundred dollars ($100) or,less.) Additional
Total No 0
I certify that in the performance of the work for which this CITY Tel No
Fixed Appliances Not Over 1 HP U
permit is issued, I shall not employ any person.in any manner PERMIT +��
so as to become subject to the Workers' Compensation Laws Range_ Heater_D W APPLICANTJCm � 2 �- d
Oven •_ Dryer_W M ADDRESSSQ-�L Z
pp Top FAU _W H _
Dat A hcan
&. — �_ _ -�- �
Hood Fan _Other_ CITY Tel No p
NOTICE TO APPLICANT' If, after making thi Certificate of Disp Room Air Cond.— LICENSE OR
Exemption, you ,should become subject to the Workers' I REG NUMBER Class
Compensation provisions of the Labor Code,'you must forth- Power Apparatus& Large.Appliances DISTRICT NO PROCESSED BY
with comply with such provisions or -this permit shall be P,KW, KVA,or KVAR
Size&Type_ H �,o Y -
deemed revoked Up to 1 Incl G
FINAL
Over 1 to 101ncl DATE
LICENSED CONTRACTORS DECLARATION -VALIDATION
_ Over 10 to 50 Incl
I hereby affirm that`I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
BY
9 (commencing with Section 7000) of Division 3 of the Busi-' Over 100 -
ness and Professions Code, and my license is in full force and -
effect Services 0
0-200 Amp. Under 600.V
License Number`�l31��Lic Class�-10 - ,
201-1000 Amp Under 600 V
Contracto � Date 107--2 Z- Over 1000 Amp or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm-that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 , Busi-, Additional Sign Branch Circuits ;
ness and Professions Code) 6 6 9 a
Misc Conduits& Conductors
O1,,as owner of the property, will do the work and the Other (See Complete Fee Schedule)— # o o,0 0 0 2 i
structure is not intended or offered for'sale (Section
7044, Bus
mess and Professions Code) `
CONSTRUCTION LENDING AGENCY ,2,.°;° 2 6,3 0
I hereby affirm that there is a construction lending agency
for the per of the woik for which this permit is / i°A?.° 2 6,7J 0 c=:
PERMIT FEE (Sub-Total)
issued(Sec 3097,Civ.C) -
36
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) Q,2 3.-8 �
Lender's'Address PERMIT ISSUING FEE i
I certify that I have read this application and state that the TOTAL FEE a
above information is correct.I-agree to comply with all County !
ordinances and State laws regulating Electrical wiring, and J
hereby authorize representatives of this County to enter upon
the above-m ntioned property for pection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE•
ignature of. erm tee Date
76A663-CE80610/74 APPLICAT CIN F ELECTOR CAL PERMIT
COUNTY OF LOS ANGELES
DEBUIRTMENT OF COUNTY LDING AND,SAFETY DIVISION ER SOB 60N Golden West
ADDRESS
LOCALITY Tem le .Cit
`NEAREST
FOR APPLICANT, TO FILL IN CROSS ST,
OUTLETS NO EACH FEE OWNER OR ����„„
FIRM NAME 1•rS Williams
RECEPT.� $ $ MAIL
FIRST 20 A'DORESS5355 N. Farna Ave '
LIGHT TOTAL 1. 1. ^'700
' CITY Arcadia � TEL. NO �I'�h /
SWITCH_ _ OVER 20 10
PLAN CHECK'
LIGHTINGTOTAL FIRST 20 25 APPLICANT
FIXTURES
OVER 20 10 ADDRESS
RESIDENTIAL APPLIANCES CITY TEL. NO.
PERMIT 7�
RANGE DRYERWTR HTR APPLICANTS r • Fowler Electric CO In
STA COOK DISP. F.A U. ADDRESS4939 Santa' Anita Ave. t
SPACE HTR. AIR COND. CITY lem le Clt TEL NO 443-1 05
CLOTHES WASH. DISHWASH. REGENNUMOR
9ER 325W CLASSC— 0
FAN OTHER 100 1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND-STATE THAT THE ABOVE IS CORRECT'AND AGREE TO COMPLY
MOTORS, TRANSFORMERS RATING WITH ALL COUNTY 0 DINANCES AND STATE LAWS REGULATING
IND HEATERS, ETC HP KW' KVA ELECTRICAL WIR IN'G
SIZE & TYPE OVER TO
I HEREBY CERT IF THAT I AM PROPERLY REGISTERED AND/OR
0 - 1 100 LICENSED AS REgU ED BY LOS ANGELES C NTY AND STATE OF �,,,
CALIFORNIA OR 7 I AM THE LEG ER OF THE ABOVE O
1 - tO 300 DE SCRIFED RE ID NTIAL PROPERTY U
PER MITEE �
10 - 50 500 SIGNATURE O
F-
U
50 - 100 1000 W
DISTRICT N0. P SSEO BY N
100 - 500 1500 Z
SIGN, GAS SIGN AND ONE CIRCUIT 500 APPROVALS DATE INSPECTO SIGNATURE
TUBE, OR
MARQUEE ADDITIONAL CIRCUITS 100 TEMP. POWER POLE '
SERVICENOTOVER600VOLTS OR200AMP ' 300 t'� UNDERSLAB WORK
SERVICEOVER600VOLTS OR200AMP 1000 ROUGH CONDUIT
TEMPSERVICE,POLE, &APPURTENANCES 500 WIRING
TEMP LIGHT OR-RECEPT. SYSTEM 300 FIXTURES ,
POWER AUTHORIZED"' l
UTILITY CO. NOTIFIED
FINAL _ 7-"-'77'
PERMIT FEE (SUB TOTAL) NOTES:
PLAN CHECK FEE -
'PERMIT ISSUING FEE 300 `77 %,r.
l
TOTAL FEE
PLAN CHECK VALIDATION CK M 0 CASH PERMIT VALIDATION cK` M 0 CASH
0.2 0 •�o
SEE BACK OF APPLICATION FOR COMPLETE SCHEDULE t� J