HomeMy Public PortalAbout9650 LONGDEN AVE_Electrical__ r
r �,1IORKERS'COMPENSATION DECLARAIJON 76AW 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT
I hePe§y affirm.•that I have a certifiyate of consent to self .
insure, or:a certificate of'Workers'Compensation Insurance, COUNTY OF LOS ANGELES. TiMple Cit BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. 550115 Company State Fund FOR,APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. &.Pools EACH NO. FEE ADDRESS 9650
1 &2-Family, Ft: 3894 $ .04 — $ IS L6CALITY
Certified copy is filed with the county building inspec-
tion department. Multi-family Sq. Ft. CROSS ST.
Date 12/18/85 JerxVrS EleCtr].0 Residential Swimming Pools OWNER OR
Applicant: FIRM NAME(WnS DevelOPMent
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Roc Light Sw._ pDRESS 4275. N. Ralc3win Ave-
IL
COMPENSATION INSURANCE First 20
(This section need not be completed If the work involved by Total No. Additional CITY r�CUYte C'A. Tel, No575=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 APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. I• Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel. No.
Date • Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT:. If, after• making this Certificate of APPLICANT sS ]eCtL1C'. TI1C.
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 `
331.1
with comply with such provisions or this permit shall be Top _ FAU —W.H. — s � % •.
deemed revoked. Hood _ Fan _Other_ CITY BalCjWinPalr]z Tel. Na43i8=2558
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG.NUMBER 259475
Class.�Q—
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PRO BY
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances „1� IL
Size&Type HP, KW, KVA, or KVAR' U
L'icense'Number 99WC;i Lic. Class C0— Up to 1 Incl. FINAL
—L
99
Contractor 'S MeC��!�te 12/18/85 Over 1 to 10 Incl. DATE VALID TION
-- Over 10 to 50 Incl., FINAL V
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
Over 100
B.&P.C. for this reason Ove �
Date: Services, Swbd., MCC&Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V R.3 9 6 1 A
❑
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V # 0 0 0 0 0 2
1 0 1 6 6 2 6
SINGLE FAMILY Temp. Power Pole&Appurtenances s oo =
HOME OWNER-BUILDER DECLARATION 1 6 6�2 6 v
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits 0 .1,3 1 -8 6
Law 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&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 1.
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 10 50
Lender's Address .
I certify that I have read this application and state that the TOTAL FEE 1
above information is correct. I agree to comply.with all County
ordinances and State laws regulating Electrical wiring, and
ereby authorize representatives of
this County to.enter upon
Leabove-mentied ppertyfinspection purposes. SEE REVERSE FOR.EXPLANATORY LANGUAGE
�„� x._12/18/85 •
Signature of Permittee Date