HomeMy Public PortalAbout8927 HERMOSA DR_Electrical__ (firm tat'[ have SAT'ON DECLARATION )68iX '°'B' APPLICATION FOR ELECTRICAL PERMIT_
I hereby a}firm that'[ have a certificate of consent to self CE-8°bG '
insure, or acertificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
ora certified copy thereof (Sec 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN 1O8
AODRESS 17 N RMVsp
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO, FEE AUT
❑ Certified copy is filed with the county builds,,,rrrLLLg inspec- 18 2-Family, Sq. Ft. $ — 8 LOCALITY up dr �� UyULQs
tion depar ment. �j Multi-family Sq. Fl.�� a3 — NEAREST 71 h
�(' vN/ Residential Swimming Poo CROSS ST.
Date I I y s APPlicant� t \ OwNER
FIRM NAME DER/ �/T/ID FNS
CERTIFI ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE Outlets: Rec_Light_Sw. 'MAIL ADDRESS � (
'/ M,,�>, L
(This section need not be completed If the work involved by First 20 /�y7
15
the permit is for one hundred dollars ($100)or less.) Total No. CITY Additional AN M,r`�K I n Tel. No, V
I certify that in the performance of the work for which this PLAN CHECK
permit is issued, I shall not employ any person in any manner APPLICANT
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITU Tel. No.
Date Applicant Fixed Appliances Not Over 1 HE PERMIT ,L/ //`�F`
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT (,iEG /"� LTQ��
Exemption, you should become subject to the Workers' Range_ Heater—D.W. _ ,1 /
Compensation provisions of the Labor Code, yob must forth- Oven — Dryer — W.M.— ADDRESS.23 ) (f ^S )'90AI/ A��y//
with comply with such provisions or this permit shall be Top FAU —W.H. RC. ��I`T G �YII O
deemed revoked. Hood Fan _Other_ CITY Tel. No. L
LICENSED CONTRACTORS DECLARATION LICENSE OR6
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER 7 Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCE$ }
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances o. rA
J/iL 7 7 S �_ /0 Size &Type HP, KW, KVA, or KVAR' �J C✓ CJ
License Number 7 tf— 1 i Class Up to 1 Incl.
�j/ DATEL O
Contractor—Date I q O V Over I to TO Incl. —` � VALID ION F
❑ Over 10 to 50 Incl NINA W
I am exempt under Sec. Over 50 to 100 Inc. BY / , n
B.BP.C, for this reason Over 100 Z
cn
Services, Swbd., MCC 8 Ponelboards
0 -200 Amp. Under 600 V
Signature��/'t/� 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. ;2 3 8 1.7 A
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit #.e'e o e e 2
I hereby affirm that I am exempt from the Contractor's License additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and .( ^ 1 13. 1 b
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors e e 11 3 1 55
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
7044, Business and Professions Code). 1. 14-86
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is o construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Ci, 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 `311 6
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 p� rt for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur of Permittee Date