HomeMy Public PortalAbout9637 LEMON AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT
1 hereby affirm that I have a certificate of consent to self CE-8066
insure, or a certificate of Workers' Compensation Insurance, { COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800, Lab C )
$A2WC141896A I ss I On Ins. Co. FOR APPLICANT TO FILL IN JOB
Policy
Na _CompanyM� 9637 E. Lemon Ave.
Certified copy'
o is hereby furnished EACH NO FEE ADDRESS
PY Y New Residential Bldgs & Pools
I� 1 & 2-Family, S Ft $ _ $ LOCALITY
L^? Certified copy is filed with the county building inspec- Y� q
tion department MUlti-family Sq Ft NEARESCROSS T
Residential Swimming Pools OWNER OR
Date 4/1 /� Applicant /�—� FIRM NAME John i Rendant
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light Sw_ MAIL as job
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work InvolvFirst 20 ed by Total No Additional CITY Tel No 447-6762
the permit Is for one hundred dollars ($100)or less.) - PLAN 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
Total No Additional CITY Tel No
Date Applicant Fixed Appliances Not Over J HP
NOTICE TO APPLICANT if, after makingthis Certificate of PERMIT
APPLICANT 'Cbb i ne I ectr i c Co. Inc.
Exemption, you should become-subject to the Workers' Range_ Heater—D W
Compensation provisions of the Labor Code, you must-forth- Oven _ Dryer — W M — ADDRESS 1607 Chestnut St.
with comply with such provisions or this permit shall be Top — FAU —W H CITY A I hambf a Tel No 282=0315
deemed revoked Hood Fan —Other—
LICENSED CONTRACTORS DECLARATION LICENSE OR - C 1 O
I hereby affirm that I am licensed under provisions of Chapter 9 Disp — Room Air Cond REG NUMBER 229847 Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO ' PROCESSED BY 0
and Profess ians_Code, and my license is in full force and effect '
Size &Type HP, KW, KVA, or KVAR
License Number 229847 Lic Class C10 Up to 1 Incl FINAL V
nf l ` Over 1 to 10 Incl DATE VALIDATION 0
Contractor T ' 0^,' - Date 11 /30/85 Over 10 to 50 Incl ~
❑ FINAL V
I am exempt under Sec Over 50 to 100 Inc BY ._. C j CL
Over 100 N
B&P C for this reasori Z
Date Services, Swbd , MCC & Panelbbards 1 15.00 10. 0 9 5 1. 1 A
0 -200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V o-o 0 0 o'2
❑ Over 1000 Amp or Over 600 V '
Exemption for Reg Maint Elect 2 ° ° 2 5 5 0
SINGLE FAMILY Temp Power Pole &Appurtenances . e o o' =
HOME OWNER-BUILDER DECLARATION + 2 5,5
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits 0-3,0 8'—8 4
Law for the following reason (Section 7031 5, Business and
Professions Code)
❑ I, as owner of the property, wilkdo the work and the M{sc 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-Totai) 15. 00
(Sec 3097, Civ C ) a
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 1 104501
_..
Lender's Address
I certify that I have read this application and state that the ..TOTAL FEE 25.50 _
above information is correct I agree to comply with all County
ordinances and State jaws 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
�e- 3/7/84
Signature of Permittee Date