HomeMy Public PortalAbout9660 LA ROSA DR_Electrical__ WORKERS'COMPENSATION DECLARATION 1 76A663 10/Bl ,APPLICATION .FORE ECTRICAL PERMIT
~I hereby affirm that I have o certificate of cm,si t to sOf CE-@06G' ,�
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec`q[J�3800,,��Lab. C.)-
P❑I cy N� t)e)0?Q pYy d D /KCa,&gL !f FOR APPLICANT TO FILL IN JOB9Z7 / /� -
Certified copy is hereby furnished. New Residential Bldgs.n8 Pools EACH NO. _FEE ADDRESS D {. /i;Lt,S'
Certified copy is filed with the cou buil 'ng insper 18 2-Fomily, Sq. FL p� 4300 $ — $ LOCALITY'
tion department. Mulfi-fomlly Sq. Ft. — NEAREST .
Datd9a}�p�, r Residential Swimming Pools OWN ,
—AWa44 "'-P•PP I i cant `/
`77`� FIRM NAME •- .,awn/
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec 70 LightSw.`]� I, 'MAIL
COMPENSATION INSURANCE Z� OV ADDRESS
This section need not he-com laced If the work Involved b First 20
( P Y Total No.�y5 Additional z. CITY rs- i i Tel.
the permit is for ono hondred dollars ($I 0)or less.) PLAN CHECK
certify that in the performance of th work for which this • APPLICANT
permit is issued, I shall not employ an person any man nerf C—
so,as to become.subject to the Work r 'Comp nsatian Laws. Lighting Fixtures First,20 5 U ADDRESS
1 t• &� Total No. Additional CITY Tel. No.
Date• Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Cerci—,ca're o4
APPLICANT
Exemption, you should become subject to the Workers' Range. Heater D.W.
Compensation provisions of the Labor Code, you must forth- Oven L Dryer W.M. ADDRESS 26'40 E, Zd ItA
with comply with such provisions or this permit shall be Top J__FAU —W.H. L
deemed revoked. Hood —. Fan OtherCITY .� Tel. No.2� 0
LICENSED CONTRACTORS DECLARATION _ ]�
. d. - Q(/ LICENSE R
DishRoom Air Can ZZ
1 hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSE BY
and Professions Code,and my license is in full force and effect. Power.Apporatus.8 Large Appliances ( }CL
q �`' /� Size 8 Type HP, KW, KVA, or KVAR' Cl O
License Number L1` /0 Lic Class I / Up to I Incl. FINAL V
/� Na`./N.✓�7Date / Over I to 10 Inc[.
Contractor a_h!s 1! S.�l.�.r..�c,r�< DATE 17 -061 -96"
��� •--�� VALIDAT N O
❑ Over 10 to 50 Incl. C/ `1—
FINAL
am exempt under Sec. Over 50 to 100 Inc. BY b,�J,6 Q u.
d
B.&P.C. for this reason Over 100 % ' / to
Ser vi )Swbd., MCC 8 Pone�l�bo,o�rd� L, va �{ • • ••P • 2 ?
Date: 0 - 2009mp. Under 600 v �e r
Signature 201 --1000 Amp. Under 600 V ( - 170.00
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Mainf. Elect. - • 1 TO 0 0'U
SINGLE FAMILY Temp. Power Pole 8 Appurtenances 0305.-85
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
Low for the following reason (Section 7031.5, Business and
Professions Code)'.
❑ I, 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)-
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) NI
...
.(Sec. 3097, Civ. C.). -
PLAN.CHECKING FEE- .. ..
Lender's Name
PERMIT.ISSUING FEE
Lenders Address pP
certif fh I have read this application and state that the TOTAL FEE _
above int motion is correct. I agree to comply with all County r
.,dm
-n sand State laws regulating Electrical wiring, and
hereb author, a representatives of this County`to enter upon -
the ve-m tinned property for inspection purposes.
• SEE REVERSE FOR EXPLANATORY LANGUAGE -
S i1J <<,
Signature of Permitt Date -