HomeMy Public PortalAbout8908 HERMOSA DR_Electrical__ TION
• Wm that I have a certificate
of Consent ON 76.663 p,a, APPLICATION FOR ELECTRICAL PERMIT {�
1 hereby affirm that I have a certificate of consent to self insure, CE-BceG u
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec. 3800,Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB ^
❑ Certified copy is herebyfurnished. EACH NO. FEE ADDRESS C/
New Residential eltlgs.8 Pools
❑ 1 & 2-Family,Sq.Ft. S — $ LOCALITY
Certified copy is filed with the county building inspection
department. Multi-family Sq.FL — NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR ./J
FIRM NAME,,/[J PIP_z{I [J
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ree_ Light — Sw. — MAIL A /
COMPENSATION INSURANCE ADDRESS 1
(This section need not be completed if the work involved by the First 20 CITYI.No.
permitis for one hundred dollars($100) or less.) Total No. Additional !� G
1 certifythat in the performance of the work for which this permit PLAN CHECK
P APPLICANT
is issued, I shall not employ any person in any manner so as to
become subject to the WorkersCompensation Laws. Lighting Fixtures First 20 ADDRESS
Z—/ 7 Additional
Total No. CITY _ Tel.No.
Date Applicant _
NOTICE TO APPLICANT: If, after Is Certificate of APPliances Not Over 1 HP PERMIT `.,,oA 1 T
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ DW _ APPLICANT [[.wit.-- )
bXA—
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS 1cA L�L
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. CITY Tel.No.—
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 DISP. — Room Air Cond. UCENSE OR Class.
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. �9 PR S D BY
Size& Type HP,KW,KVA,or KVAR DV
License NumberLie.Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE �J _ Z VALIDATION
Contractor Date Over 10 to 50 Incl. /j 0
13 FIN- U
I am exempt under Sec. Over 50 to 100 Inc, BY W
B.&P.C.for this reason . Over 100 d
Services,Swbd.,MCC& Panelboards , N
Date: 0- 200 Amp,Under 600 V
Signature 201 - 1000 Amp,Under 600 V e 8 9 7 1 A
Over 1000 Amp.or Over 600 V # o o 0,0 e 2
❑ Exemption for Reg.Maint.Elect. ' e e 2 5 S 0
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION e e o '2 8 5 0-0I hereby affirm that I am exempt from the Contractor's License Law Sign with One Brandi Circuit
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits 0 217-88
Code):
Misc.Conduits& Conductors r '
as owner of the property,will do the work and the structure
Is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ,
and Professions Code).
CONSTRUCTION LENDING AGENCY -
I 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.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lenders 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
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
/J
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Signah ermi Date