HomeMy Public PortalAbout9648 LONGDEN AVE_Electrical__ ,
11S'COMPENSATION DECLARATION 768663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm4ffirm''that I have a certifir`ate of consent to self � CE-806G ,
insure, or a certificate of Workers'Compensation Insurance, ► COUNTY OF LOS'ANGELESBUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.) I T�llple I L'�7
Policy No 5501 15. Company Stat-e T.im I FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. i New Residential Bldgs. &Pools EACH NO. FEE ADDRESS 96 8
® 1 &2-Family,Sq. Ft. '48 $ — $ LOCALITY
Certified copy is filed with the county building inspec-
tion department. Multi-family Sq. Ft.. — NEAREST
r Residential Swimming Pools CROSS ST.
D.ate_./io�85 Applicant Jer S El�i-C I OWNER OR
FIRM NAME QWeM Dewe.
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight' . MAIL
First 20 ';
_
COMPENSATION INSURANCE � Sw. ADDRESS 4275 N. Baldwin Ave.
(This section need not be completed if the work involved by Tota) No.- Additional CITY El Nxite, 0k. Tel. No.575-0503
the permit is for one hundred dollars(;100)or less.) PLAN CHECK
I certify that in the performance of the work for which this I APPLICANT
permit is issued, I shall not employ any person in any manner I
so as to become subject to the Workers'Compensation Laws. j Lighting Fixtures First 20 ADDRESS
Total No. Additional
Date Applicant CITY, Tel. No.
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after makingthis Certificate of
Exemption, you should become subject to the Workers' Range_ Heater_D.W. _ APPLICANT Jerzy S EaZ' r_tr3LCs IM.
Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M._ ADDRESS3S76
Dagft. 3dd
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY Tel. No. 8-2558
Hood _ Fan _Other_ BA1d1wT.in Park 33
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG.NUMBER Clas _
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT N PROCES
and Professions Code,and mylicense is in full force•and.effect. /)
IL
Size&Type HP, KW, KVA, or KVAR' L V
License Number 259475 Lic. Class C10- Up to 1 Incl. FINAL
Contractor s S EleC- Date 12/18/85 I Over 1 to 10 Incl. DATE 129
VALIDATION 0
Over 10.to 50 Incl. FINA V
❑ I am exempt under Sec. Over 50 to 100 Inc. BY f 6
BAP.C. for this reason Over'1.00 y
Services, Swbd.., MCC&Panelboards
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under'600 V ;93960A
El
Over 1000 Amp. or Over 600 V
Exemption for Reg. Mai.n.t. Elect. # o o o o o 2
SINGLE FAMILY Temp. Power Pole&Appurtenances ° 1 b 2 b
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 ° ° 1 661 2 b=
Law for the following reason (Section 7031.5, Business and c�
Professions Code):
❑. Misc. Conduits&Conductors 0 1,3 1 -8 6
I, as owner of the property, will do the work and the
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
Lender's Address
1 certify that I have read this application and state that the TOTAL FEE $166.26
above information is correct. I agree to comply with all County
ordinances and State laws regulating.Electrical wiring, and
hereLby authorize representatives of this County to enter upon
the�Pylove-mentlonecl.aro . rty for, .spection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
.12
Signature of Permittee Date