HomeMy Public PortalAbout9861 LONGDEN AVE_Electrical__ " re ' W4RKERS'CpNWNSATIONDECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECU CAL PERMIT
IfierebySO;anAV'Ihave a certificate of consent to self CE-903,
insure, pr 0 carti�icote of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a ceflifted copy thereof (Sec. 3800, Lab. C.)
fpQlicy No. Company.y FOR APPLICANT TO FILL IN JOB 1r r
Certified copy is herebyafumisRed. New Residential Bldgs. &Pools EACH NO FEE ADDRESS
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. b $ — $ LOCALITY �� �•. (y r�
tion department. mutir-family Sq. Ft7 NEAREST
CROSS ST
OW �r 1•/
Date Applicant Residential Swimming Pools L `
OWNER T j
� FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec` ight�Sw._ MAIL
COMPENSATION INSURANCE / ADDRESS
(This section need not be completed if the work involved by First 20 CITY f -� 7. '+
the permit Is for one hundred dollars($100)or loss.) Total No. •_ Additional ) �� /j�� Tel. b.
PLAN CHECK )).. /► /� ,_...,
I certify that in the performance of the work for which this APPLICANT lgr
,"IS/ire=�
permit is issued, I shall not employ c y erson in any manner Lighting Fixtures First 20 ;ZV ADDRESS ; �y /i.� r
so as to become subject to the Work C o m p e ion Laws. -7 • +/
+'� Total No. Additional 130
CITY ` , ,
i / Tel. No. ' �{
Date Applicant 'f -�-�— Fixed Appl'ances Not Over 1 HP PERMIT L / ` ' Y
NOTICE
Exemption, youLlshould lbecofine subjecttlis to hetlficate Wotke sf Range`. Heater�D.W. APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven Dryer _.l._W.M. ADDRESS
with comply with such provisions or this permit shall be Top FAU -^JK—W.H.
deemed revoked. Hood Fan —Other— CITY
LICENSED CONTRACTORS DECLARATION Disp' Room Air Cond. LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 -�- — REG. NUMBER Clas
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. ^ PROCESSEQBY a
and Professions Code,and my license is in full force and effect. �/
Size&Type HP, KW, KVA, or KVAR � t 0 O
License Number Lic. Class Up to 1 Incl. FINAL
U
Over 1 to 10 Incl. DATE � VALIDATION cc
O
Contractor Date Over 10 to 50 Incl. 0
FINA U
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 tl
Date:
Services, Swbd., MCC 8 Panelboards 7t,` � Z
0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
El Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License �
Law for the following reason (Section 7031.5, Business and Additional Sign Br n�h( its '' 01 a_ A
j
of 55 ions Code): ,� f ' o o o 0 0 2
as owner of the property, will do the work and the Misc. Conduits& onductors
kips
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ ( o 12 9, Cl 0
Business and Professions Code).
CONSTRUCTION LENDING AGENCY o 0 I , 9. O
I hereby affirm that there is a construction lending agency for i 4—F8
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 /
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
h authorize (sjart�ives of this County fo enter upon
bove-mnti ne for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE'
Si nat o errAit a Date