HomeMy Public PortalAbout9021 PENTLAND ST_Electrical__ • WORKERS iwe a ceSATION DECLARnt to F - CE 8a3 teat APPLICATION FOR, ELECTRICAL PERMIT
? I hereby affirm that I have a cerhflcate'of consent to self insure J�eoeG , `
of a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY'
copy, c thereof (Se3800 Lab C)•
k' a.
Pdcy Nei� um
- - ,Comparry, " I eFOR APPLICANT TO FILL IN JOB
ADOPTERS 9O Q_}L QVC
-' ❑ Cerldied copy is heretiy fishetl • 1 New Residential Bldgs & Pods EACH NO FEE
1 • , LOCALITY
�. Certnied copy rs•filed with the county.bu,lding inspector t 8 2-Family SQ Ft $ _ $ NEAREST
department_., S w _ _ Multi-famAy Sq Ft NEARS Si 6 hYs�
' Applicant +� " , Residential Sv1nmming Pools 1 OWNER rl Ra t,� ' r
Data II __
' l,• \'"_-•. ' 1• h FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERSMAIL Z '
m \, , COMPENSATION INSURANCE Outlets Rec_Light Sw y + ADDRESS
\ (This section need not be completed If the work involved by the .First 20(
`permit^e for one hundred dollars($100)or lees) 1, l Torsi ' Additonal • CITY Tel No
lacerfify that in the performarx:e,of the for which this permit '1 '` PLAN CHECK ,
4 issued•I shall not employ,arty person ,n Ery manner so as to , {'` ti Y 1\ AD�RES3
` become subject to the,Workers Compensation Laws Lighting Fixtures First 20 _
Y..i
I1 '- O e Total No Adtlnionel - - CITY - r Tel No m r
Det. 8. Appioant ��'r'
NOTICE AP CANT If after making' this rtdoate d Fixed,Appliances Not Over,1 HP • I PEBMNT
Exemption you should become subject to the Wodcers Compensahon+ Range— Heater_ DW ' APRIICANi '
provisions of the'Lebor'Coda you must forthwith comply with'such Oven�_ Dryer _ W M + WADDRESS
pro nslons or the permit shell be deemed revoked s . rTop — FAU _ WH �' CITY G Tel No v `
t,•` ` v LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other-
1 hereby affirm'that I,em licensed under provisions of Chapter 9 '^ UCENSE OR
mo
'(commencing with Sechon,7000) ofyDrvlsn 3 of the Bus,nese-and Drsp — Room Air,Cond _ Cl.. '
REG NUMBER
Professore Code and'ah,license,s,n full force and effect ' DISTRICT NO PROC v
_ rPower Apparatus 8-L.a-rga Appliances r
8. Srze & Type HP KW KVA or KVAR �O
License Number ' Lx: Class Up to 1 not FINAL -
i Over 1 to 10 Incl' DATE VALIDATION Q
Contractor' Date' _ -' OVor 10 to 50 Ind ,
_Q 1 am exempt under Sec + O,,050 to 100 Inc FINAL
- 1
B&PC for this reason r• Over 100 J , I 1
' - Date -Services Swbd MCC&Penelboards NIP. - Z
` > 0- 200 Amp Under 600 V d
Signature 4 201-- 1000 Amp Under 600 V
- Over 1000 Amp or Over 600 V I r
❑ '.Exemption for Reg Meim Elect- _ ,r. .. " S ,
SINGLE FAMILY Temp Power Pole& Appurtenances 2
• '` HOME OWNER-BUILDER DECLARATION - Sgnlwith`One Branch Circuit
_ J• y
1 hereby affirm that I a n exempt from the Contractor a Ucense Law Additional Sign Branch irc it t ��'*
for the idkrvlrg reason(Section 7031 5 Business end Professors - 9 r7� -
Code l .e rt . ' ' s ' 330-1 25..50
>• Mist Conduits& Conductors • 1 ITEM y
I as owner-of the property will do the work and the structure Other'(See Complete Fee Schedule) 1• TOTAL-
`
' Is not intended,or offered for sale (Section 7044 Business TV IrSD ��_ D
+7 and Professions Code) ' ' V /.�/
M, ► DEM
r 4 ' CONSTRUCTION LENDING AGENCY � � ti - " r + - � •.'rre�
I hereby affirm that there is.a construction lending agency for the `J•n�(In�'I
performance of the work for which this permit,s issuatl(Sec'3087 q PERMIT FEE ` - . •(Sub-Tolat �IIYRS •Go
Civ C) I fy �rr,' ' '+.�pO
• ,t ,i r tom; PLAN'CHECKING FEE'' _ a / ," ` qg-t�JLll 8/2L p7
Lenders Name - \ r '
n I _PERMIT ISSUING FEE
Lenders Address'
192
ss" _ J 1' AM11:4'2,,
certify that I have read this apploaton and state that the above, i TOTAL FEE � u s » 5 • - r.
' •:,Imforma 'hon,s correct I agree to WMPIY with all County ordinances '
and State laws regulating Electrical wining and hereby authonze ' r
representatives of this County to enter upon the above-menboned
, pro arty for'inspection pu poses '
`n SEE REVERSE FORE%PLANATORV LANGUAGE
Signature of Permmee ,Date