HomeMy Public PortalAbout6209-6211 GOLDEN WEST AVE_Electrical__ f?^ 1+NORr' COMPENSATION DECLARATION A '° 'B'
that
-rtY�,'eby.dfirm shot Il have a certificate of consent to self CE806G APPLICATION FOR ELECTRICAL PERMIT
` insure,ior a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a j ted copy thereof (Sec38 Lab C )
Pol cy o Company �O CtM+ t FOR APPLICANT TO FILL IN JOB _
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS f9
❑
1 & 2-Family, S Ft E _ $
LOCALITY
Certified copy is filed with the county building inspec- Y- q
tion department Multi-family Sq Ft ' NEAREST
CROSS STS
Date-7--i Applicant ' Residential "" I PoolsSaAl-,, ,OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERf' jj� �-'' t 't FIRM NAME d
Outlets Re Ligh Sw_ ti MAIL
COMPENSATION INSURANCE ADDRESS
First 20 '
(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
I certify that in the performance of the work for which this APPLICANT
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 ADDRESS
Total No Additional
CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If, after making this Certificate of APPLICANT V /^
Exemption, you should become subject to the Workers' Range_ Heater_D W bq
—
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W M _ ADDRESS L 1
with comply with such provisions or this permit shall be Top — FAU —W H — r
deemed revoked Hood _ Fan _Other_ CITY.& b Tel No u
LICENSED CONTRACTORS DECLARATION LICENSE OR r
Disp _ Room Air Cond Class
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER, I —�1�7
(commencing with Section 7000) of Division 3 of the Business power Apparatus 8 Large Appliances DISTRICT NO PROCES D BY 0
and Professions Code,and my license is in full force and effect ���'' y,
/^ Size 8 Type HP, KW, KVA, or KVAR LJ�V t 0
License Number ` Lic•Class 1t
•—� Up to 1 Incl FINAL ^ n 0
Contractor Nue LtrDate / '� p Over 1 to 10 Incl DATE �Y�J/C/J yA ATION
Over 10 to 50 Incl FINA W
❑ I am exempt under Sec Over 50 to 100 Inc BY a
N
B&P C for this reason Over 100 Z
Date Services, Swbd , MCC 8 Panelboards loop.
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 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits 4 9 3t 3 A
Law for the following reason (Section 7031 5, Business and
Professions Code) # 0 0 0 o 0 2
❑ j, as owner of the property, will do the work and the Misc Conduits 8 Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ I1 o l 7 4A 0
7044, Business and Professions Code) , o o l 74, 1 0csi
CONSTRUCTION LENDING AGENCY t) Q.7 1 786
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
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application 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 outh ize r resentotives of this County to enter upon
th bove- nti ed perry for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of PermiTted PermittedDate