HomeMy Public PortalAbout9526 KENNERLY ST_Electrical__ WORKE TION DECLARATION CE 806G '°'B' APPLICATION FOR ELECTRICAL PERMIT
I�hEecdby giffirm th, certificate of consent to self
insure, or a certificc. . a Wor War '
Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, LaE�.r,.
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. EACH NO. FEE ADDRESS ti
PY Y New Residential Bldgs. & Pools
❑ Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY �-
tion department. Multi-family Sq. Ft. NEAREST
Residential Swimming Pools CROSS ST. C Z
Date Applicant OWNER OR
IF
FIRM'NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE 20 ADDRESS
This section need not be completed if the work involved b First ti
( p y Total No. Additional CITY�� �E I Tel. Noa , 3
the permit is for one hundred dollars ($100)or less.)
PLAN CHECK
1 certify that in the performance of the work for which this APPLICANT
permit is issued, I shall note
mploy y person in any manner
so as to become subject to the Wor ers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel. No.
�2 Z 7-Sly Applicant
Date a `� Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, of making this Certifica e of APPLICANT
Exemption, you should bec a subject to the Workers' Range_ Heater—D.W. —
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. Hood Fan _ Other— CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PMBY BY
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances /, A.
Size 8 Type HP, KW, KVA, or KVAR' �� V
License Number Lic. Class Up to 1 Incl. FINAL 4)
Over 1 to 10'Incl. DATE VALIDATION 0
Contractor Date Over 10 to 50 Inc]. FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100
Date:
Services, Swbd., MCC& Panelboards ►
0 -200 Amp. Under 600 V
0
Signature 201 - 1000 Amp. Under 600 V ( Z
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole & 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
Law for the following reason (Section 7031.5, Business and
(Prroofess ns Code):
LJ"' I, as owner of the property, will do the work and the Misc. Conduits& Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— ,
7044, Business 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 PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE +J
Lender's Address �Q
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 authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of-Per M ee Dat