HomeMy Public PortalAbout9624-9626 LONGDEN AVE_Electrical__ r � 1
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WORKERS'COMPENSATION DECLARATION 76663 CE-806G. IDiel APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance,' COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sµ 3800, Lab. C.))
Policy No] x 3.i� Company 0 1� C1R syA.r y FOR APPLICANT TO FILL IN JOB / •^tom A..�
Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs. $ Pools
1 $2-Family, $ — $ LOCALITY t:Pla—
Certified copy is filed with the county building inspec- y, Sq. Ft. T� t C-j 7-
tion de artm nt. Multi-family S . Ft. — NEAREST
P Residential Swimming Pools I CROSS ST. C mtau= 0/l y z
Date Applicant 17/+�Nt6 OWNER OR a�
I FIRM NAME J �SM/���/Mw1L`GMA�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._First MAIL /�1 r j/C/( L i/.D
COMPENSATION INSURANCE ADDRESS W
(This section need not be completed if the work involved by tCITY Z(3
the permit is for one hundred dollars($100)or less.) Total No. Additi l ZZ �ona �,PLAN-eHEE /7S4 G Tel. No. f 9L 7
I certify that in the performance of the work for which this' APPLICANT 0 Le*C"
permit is issued, I shall not employ any person in any manner'
.so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS IVp0
Total No. Additional ? ��
��C�,a f 9 Tel. No.
Date Applicant CITY Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT 3,01 -ICSy1'4— HMFeAl"
Exemption, you should become subject to the Workers' Range_ Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M.— ADDRESS Z2_ rb w9y Jt1fTr/e1f Bpyp,
with comply with such provisions or this permit shall be Top — FAU —W.H. — n
deemed revoked. CITY yA �i9f5;[s� Tel. No FJ2,6qf 7 1 s
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
LICENSE OR /'
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER /p z0 Class. 1
(commencing with Section 7000)of Division 3 of the Business power Apparatus$Large Appliances DISTRICT NO,�`/ PROC BY D�
and Professions Code,and my license is in full force and effect. / y
Size$Type HP, KW, KVA, or KVAR
License Number IGS Lic. Class !!' Up to 1 Incl. FINAL
q;j Over 1 to 10 Incl. DATEO
ContractorDate_.+ / a o� V DATION H
❑ Over 10 to 50 Incl. FIN W'
I am exempt under Sec. Over 50 to 100 Inc. BY D.'
B.$P.C. for this reason Over 100 Z
Date: Services, Swbd., MCC$Ponelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V ;2 Ll 3 S 5 A
SINGLE FAMILY Temp. Power Pole$Appurtenances # 0 0 0 0 0 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ) - 2550
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 o 0 0 2 J 0
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits$Conductors 04,02-86
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.). l
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address j 5 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 injipection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee Date