HomeMy Public PortalAbout9102 HERMOSA DR_Electrical__ WOrm'th CI hci Ne ATIONcateDECLARATION
corse 76A0 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT
0 W1
I hereby'affirm'that haver certificate ns consent.to self cE.8o5G _ I
insure, ora certificate tof hereof
(Sec. 3' Compensation Insurance, COUNTY,OF LOS ANGELES DEPT. OF PUBLIC WORKS
or o ceyiifed copy thereof (Sec. 3800, Lab. C.) �` '
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools ' EACH NO. FEE ADDRESS 102 I-lermosa y
r_1'Ceilified copy is filed with the county building inspec- 1 8 2-Family, Sq. Ft. i S _ g LOCALITY Pr iti
lion department. Multi-family Sq. Fl. I — NEAREST
T,
Date CROSS S
d
Residential Swimming
Pools
Applicant ( - OWNER OR
RM NAME YdnIL •-/
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_Light_Sw. MAIL
COMPENSATION INSURANCE 'First 20 ADDRESS
(This section need not be completed if the work Involved by Total No. Additional CITY T.I. Nc(.$j
the permit is for one hundred dollars ($100)or less.) PIAN 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
• at,-,A
/�( Addifionhl
Date /1'— aG� \ Total No. t CITY Tel. No.
App aft r� Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO Aou should
T: Ib after making this th ti Wore of
Exemption, you should become subject to the Workers' Range— Heater—D.W. _ APPLICATION
Compensation provisions of the Labor Code, you must forth Oven — Dryer —W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. I CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Hood — fan —Other_
Disp. — Room Air Cond. L LICENSE OR
.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PRO ED Y >_
and Professions Code,and my license is in full force and effect. - d
Size &Type HP, KW, KVA, or KVAR Q
License Number " 67- Lit. Class C—/V Up to 1 Incl. FINAL U
ControctoalleC Z119;tq Mct Datet'3]"' Over 1 to 10 Incl. DATE VALIDATION
Over 10 to 50 Incl., FINAL 0
1 am exempt under Sec. Over 50 to 100 Inc. gy W
B.BP.C. for this reason Over 100d
��ss
J
Date: Services, Swbd., MCC & Ponelboards. Z
0- 200 Amp. Under 600 V - No, Z—,
Signature 201 - 1000Amp. Under 600 V -
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Moint. Elect. �
SINGLE FAMILY Tem Power Pole 8 A _
HOME OWNER-BUILDER DECLARATION p ppurtenances
I hereby affirm that I am exempt from she Contractor's License Sign with One Branch Circuit
Low for the following reason (Section 7031.5, Business and _Additionot Sign Branch Circuits 3307 59.00
Professions Code):
El1, Conduits 8 Conductors VMD I, as owner of the property, will do the work and the �
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , 3N7 59.00
Business and Professions Code). ; _±
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for z�Y AC•CT.i
the performance of the work for which this permit is issued PERMIT FEE 1 (Sub-Total) 33
I-1
(Sec. 3097, Civ. C.). 1,WEl}] 9.u_
PLAN CHECKING FEE 1 ITEMS
Lender's Name n '
PERMIT ISSUING FEE O TOTAL 29- 00
Lender's Address -
I certify that I have read this application and state that the TOTAL FEE , CHECK 29.011
above information is correct. I agree to comply with all County 1 CNHNVE .1��
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
ZEermKee Date
OOOu-GCID1 111 ', 4
Signature of Per ee - ate bb42 1 AM 9:43°i