HomeMy Public PortalAbout5509 PARMERTON AVE_Electrical__ r
�YORKERS COMPENSATION DECLARATION r CEG 1001 APPLICATION FOR ELECTRICAL PERMIT
hereby rifhrmvthat I have a certd,cate of consent to,self insure K
or e cof Workers Compensation Ireuraree or a certified COUNTY OF LOS A
copy, BUILDING AND SAFETY
copy,thereof hereof((Sec 3800 Lab C) 1 4
Policy No Company FOR APPLICANT TO FILL IN , JOBy�1
_❑ Certified copy is hereby furnished EACH NO FEE t ADDRESS 17 N. 1"M err` �7V1:.
< r New EACH Bldgs 8 Pods
1 H 2-Famn1 $ — S LOCALITY
'',❑•
Certified copy is inled•vnth the county�bunldnng inspection Y Sq Ft "It
department , Multi temJy Sq Ft NEAREST +,
Date+ ,' + Applcanl •'• ' Residential Swimming Pools OvECROSA O I ,
FIRM NAME rA
-� CERTIFICATE OF EXEMPTION FROM WORKERS { Outlets Rac— Light _ SW I l 1 i�DaE9S t' ^
y COMPENSATION INSURANCE S-{• `
(This section need not be completed if the work Involved by the First 20.E _
permit is for one hundred dollars ($100)or less) Total No Additional + ♦ CITY so,'I A ,2 el No �, 1 d I Cg JA
I I certify that in theiperformerce of the work for whchlths permit 1 PIAN CH� i f 1 .l
I* Issued I shall net employ any person in any manner,so as to 1 > • >}' t _
become sublect,to lhe,Workers,Compensation Laws - , Lighting Fixtures First 20 ADDRESS 1
1' Additional I �'
11 APP ' Total No CITY Tel No
v Date L ISP - - Fixed Appliances Not Over 1 HP '
NOTICE TO APPLI A T If ,af „ making this hcate d PERMIT
r Exemplron you shouN become subject to theVubrker Compensetcn , Range_ Heater_ D W .. APPU��+T
proviworns off the Labor Cade you must forthwrth comply vnth such Oven Dryer'_ WM r 1 ADDRESS
i , provisions or thns'permit shall be deemed revoked ' 'Top FAU WH
_
�—
' LICENSED CONTRACTORS DECLARATION Hood Fan _ Other_ r r CITY •• Tel No
hereby affirm that_l'am licensed under yrovnsnons of Chapter-9 e Disp Room Air Cond . LICENSE OR Chis
(commen>Gn0 with Section 7000) of Diwsron 3 of the Business and REG NUMBER -
Professions Code,and my Incense r9 in full force and effect DISTRICT N O� SSED BY y
t Pover,Apperatus& Large Appliances . jyK7 Jam'
-t + Size 8 Type HP KW KVA or KVAR l ^
r
License Number Lie Class upto1 Ind _ - FINAL • - 8
DATE> (Date -,s Over 1 to 10 Incl �9 , ••a VALIDATION +� O
IX
Contractor _ „ Over 10 to 50 Incl FINA '
c U
am exempt under Seo _ Over 50 to 100 Inc F1 '- ' {{yyI
„ r BBPC for this reason Over 100 �QC�� ,t N
Date
Services Swbd MCC 8 Panelboarcls • - a , '�`3307 _ 1
- 0- 200 Amp Under 600 V n
Signature 201 - 1000 Amp-Under 600 V r: - -- ,. - .a 1 ITEMS ^
' ❑ Exemption for Reg Mannt Elect Over 1000 Amp or Over 800 V i T_ .' TOTAL25 - 0
SINGLE FAMILY, ' • Temp Power Pole A Appurtenances , , 9 CHANGE ,OO
HOME OWNER-BUILDER OER DECLARATION Sign with One Branch Cecat ,
I r the'reby affirm that am exempt from the Connectors License Law Additional Sign Branch Circuits
r for the'folbwing reason(Section 7031 5, Business and Professions g r -1 _,�• __- ,0, �t �r ,
Code) t ^ OOOO-0401 ' 3/ib/�
'•f�1 ' Misc Conduits 8 Conductors - y y _
loL I es owner of the property viii do the of and the structure '
is not intended or.oHered for Bale (Section 7044 BusnnessY Other(Sae Complete Fee Schedule) — ,r 1923 1 �' 943
. and Professions Code) - - - - - , ' . . .r=.
A i
' r 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(Sec 3097 PERMIT FEE (Sub-Total) + '•
Civ C),
y
Lenders Name PLAN CHECKING FEE •r • r { , v
• 'PERMIT ISSUING FEE
Lenders Addmss
I certify that I have mad this application and state that the above TOTAL FEE
nnformeten is correct I agree to comply with all County ordinances it '
i, and State laws regulating Electrical wnnng and hereby authorize ,
representatives of this County to enter upon the stove-mentioned 1 - - -• - - v
pro rty for inspection urposes
_ f2 SEE REVERSE FOR EXPLANATORY LANGUAGE,• , { _ r
lure of rmr� /� -Date .. I r +~