HomeMy Public PortalAbout5317 NOEL DR_Electrical__ W'. .'
rm th COMPENSATION DECLARATION C6A� 10/81APPLICATION FOR ELECTRICAL PERMIT
trm that I have a certificate of consent to selfertificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereodmpany
ec 3800 Lab C
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ricy No FOR APPLICANT TO FILL IN JOB ADDRESS ���
Certified copy is hereby furnished' ' New Residential Bldgs &Pools EACH NO FEE
❑ ; _
Certified copy is Bled with the county building inspec 1 8 2 Family Sq Ft $ LOCALITY
do de rtment ,l Multi family Sq Ft CROSNEARS ST �L.��4�
Date Applicant ���//-/V� Residential Swimming Pools OWNER ORS•
CERTIFICATE OF EXEMPTION FROM WORKERS Q FIRM NAME D 1�/y /P�/3
COMPENSATION INSURANCE Outlets Rec Light�Sw ADDR 4�A- 1W.
(This section need not be completed if the work Involved by 8
First 20
the permit Is for one hundred dollars($100)or less) Total No Additional CITY—WIW G! Tel
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 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICANT
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
with comply with such provisions or this permit shall be Top — FAU —W H — dl--7,&deemed revoked CITY Tel No
Hood — Fan —Other
LICENSED CONTRACTORS DECLARATION —
% LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 'sp — Room An Cond REG NUMBER Class
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO P ED BY d
and Professions Code and my license is in full force and effect Power Apparatus 8 Large Appliances W 0
y' r Size&Type HP KW KVA or KVAR t V
License Numbers1 Lic Class Up to 1 Incl FINAL �j 0ZU &lL�n Over 1 to 10 Incl DATE f FINA 0
Contractor to v 7 VALIDATI
❑ Over 10 to 50 Incl
I am exempt under Sec Over 50 to 100 IncBY N
B 8P C for this reason Over 100 Z
Ser MCC 8 Panelboards l
Date 0 200 Am Under 600 V �/ '
0
Signature 201 1 mp Under 600 V
❑ 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 23761 A
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits # • • • • • 2
Law for the following reason (Section 7031 5 Business and
Professions Code) ) — 5750
❑ 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)_ , • • • 57 505
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 0106-86
j 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
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 jaws regulating Electrical wiring and
Ae
eby authorizer presentatrves of this County to enter upon
�ove nI orrd property forins ction purposes SEE REVERSE FOR0EXPLANATORY LANGUAGE
fic
a re of PermHt Dote