HomeMy Public PortalAbout9030 PENTLAND ST_Electrical__ 1 GR ZERBCOMPENSATION DECLARATION 76AS63 /n APPLICATION FOR ELECTRICAL PERMIT
11h.reby affirm fhat,I have a Certificate of consent to sell Insure
or a yenlhcate of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy Vrdof(Sac
QQ3aO/O Lab C)S 11 AV
/� I " i7 �y�
Policy NO ZZ0464 Company />r/(� AVAI ) FOR APGLICANr TO RLL IM gJOB
ppRE$5 �O�(J ��iv r L ry� T
❑ Cerldred copy is hereby fumishedNew ResWentiel Bldgs d Pools ( EACH NO - FEE
❑1 Cenlfied copy Is filed with the county budding inspection 1 8 2 Family Sq Ft
$ _ $ LOCALITY TeY� LE C/ T
department 'r, r Mum family Sq Ft CROSS ST
Date 9-i Apphcerit ,T 4L/�7?/LE�Ld Residential Swimming Pools - ^� AgSE�OR
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CERTIFICATE OF EXEMPTION FROM,WORKERB Outlets Rec LOWNER OR
ight Sw 3 `f .� t \ FIRM NAME RAOE ZO PAACEI Z3
COMPENSATION INSURANCE ^' r
FID:I 20 MAID t
(This section need not be completed if the work Involved by the Total No Additional O - ADDRESS ,9 0 P /� �fj/✓,L7 T
permit is for one hundred dollars($100)or lase) _
I certify that in the performance of the work for which this permit - - CITY — Tel nb Z S
2,134
is issued I shall not employ any person in'any manner-so as to 4
become subject to the Workers Compensation Laws Lg Ming Fixtures First 20 PLAN
Total No Additional ADDRESS
Dale Applicant
NOTICE TO APPLICANT Ii ailer,meking this Certificate OR 20A 120V BRANCH CIRCUITS Certl/Icete of CRY Tel No lb3
Exemption you should become subject to the Workers Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
Er (J
provisions of this permit shall be deemed revoked 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION - - ADDRESS 7 - - 2c-N sja a
I hereby affirm that 1 am licensed under provisions of Chapter 9 15 OR 20A 20BV TO 277V LIGHTING EACH O
(commencing with Section 7000) of Division 3 of the Business and _ _ _ _ CITY h Ly Tel No U
Professions Code and my license Is In full force and effect RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR ! /7 Ir
f Power Apparatus 8 Large Appliances _ REG NUMBER ., V O G� O
License Number 4`�1Q 1910 Lw Class Zi� Size 8 Type HP KW KVA or KVAR DISTRICT NO PROCESSED U
//� ['S Up to 3lriU 0 LULU
Contractor\)LL/qy 611IFA L614M /-I �k / c/ _ Owe!3Io 101nc1 FlNAL
❑ Over 10 to 50 Ind - DATE Z
I am exempt under Sec _ Over 50 to 100 Incl VALIDATION
100 -- BY
m
B BP C for this reason Over By
Seces Swbd MCC 8 Panelboards RNALf
Date 0 200 Amp Under B00 V
Signature 201 1000 Amp Under 800 V -
❑ _ Over 1000 Amp or Over Boo V _ w
Exemption for Reg Maml Elect
n
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Qrcud r ACLT.i
I hereby affirm that I am exempt from the Contractor a License Law
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits__ _ - 3397 43.-5
Code) r _ Fu^
❑ I as owner of the property will do the work and the structure MW Conduits 8 Conductors • 1 ITEM
ly
Is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) , TOTAL 43 - 45
and Professions Code) CHECK 43.45
CONSTRUCTION LENDING AGENCY A�t��t, 1l1v
I hereby affirm that there Is a construction lending agency for the _ Cl LtJJIt M3E _ .0
performance of the work for which this permit is issued (Sec 3097 PERMIT FEE - _• (Sub Total)
Civ Civ C) '
10 1 y
PLAN CHECKING FEE_ ._ • _ I - - ( Z ' _ 0000-OOC1 9/10/92
Lender s Name ' -
PERMIT ISSUING FEE _ _ , _ i 3 55Q9 1 AM S:5
Lenders Address
I certify that I have reed this application and state that the above TOTAL FEE
Information is correct I agree to comply with all County ordinances ✓ '
and State laws regulating Electrical wiring and hereby authorize
rep ntalives of thisufR�to enter upon the above mentioned
ope for inspect io ur 'Ops SEE REVERSE FOR EXPLANATORY LANGUAGE
9-�89v -
EOFAPPIICM? DENT MTE