HomeMy Public PortalAbout5344 PERSIMMON AVE_Electrical__ ION
i. WORKERS' I have a cerci DECLARATION l' CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affizm that I have a certificate of consent to self CE-806G
i insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, L ) J/�_
Policy No ompany / } FOR APPLICANT TO FILL IN I JOB
Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs. &Pools
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ �; LOCALIAV
tion department. Multi-family Sq. Ft. I
NEAREST CROSS T. ZJ
' Residential Swimming Pools OWNER OR
Date/=L3Applicant FIRM NAME i
CERTIFICATE OF EXEMPTION ER WORKERS' Outlets:•Rec�Li ht MAIL
9 �Sw.._a
COMPENSATION INSURANCE ADDRESS C�5.
(This section need not'be completed If the work Involved by First 20
the permit Is for one hundred dollars($1.00)or less.) Total No. Additional t 'CITY—�� Tel. No �/
I certify that in the performance of the work for which this PLAN CHECK
permit is issued, I shall not employ an
-APPLICANT
p p y y person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
1, Additional - I.
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after .making this Certificate of f PERMIT
Exemption, you should become subject to the Workers' Range_ Heater_D.W. _. APPLICANT
Compensation provisions of the Labor Code, you must forth- Oven _Dryer —W.M.— J ADDRESS
with comply withi such provisions or this permit shall be Top _•FAU —W.H. — I1
deemed.revoked. I CITY Tel. No
—Fan'Fan _Other
LICENSED CONTRACTORS DECLARATION _
' LICENSE R
_ —
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER. Class.
(commencing with Section 7000)of Division 3 of the Business power Apparatus 8 Large Appliances i. DISTRICT NO. RROC BY per.'
and Professions Code,and my license is in full force and effect. Type
Size&T e HP, KW, KVA, or KVAR• (J
License Number Lic. Cass Up to 1 Incl. I FINAL CIG
Over 1 to 10 Incl. i DATE 0
Contracto VA DATION
Date 3—1S Over 10 to 50 Incl. I' S C=I
�- FINAL
El I am exempt under Sec. Over 50 to 100 Irtc. BY a
B.&P.C. for this reason i Over 100 tl
Date: Services,.'Swbd., MCC&Panelboards
0 -200 Amp. Under 600 V 90
Signature I 201 - 1000 Amp. Under 600 V I;i
I
Exemption for Reg. MainOver 1000 Amp, or Over 600 V.t. Elect. � A 6 3 3.4 A �
SINGLE FAMILY Tem Power Pole&A 2
HOME OWNER-BUILDER DECLARATION p• ppurtenances # o 0 0 o 0
Sign with One Branch Circuit
I hereby affirm that I g r exempt from the Contractor's License Additional Sign Branch Circuits I o .3a25
.Law for the following reason (Section 7031.5, Business and'
Professions Code): 0 0 0 3 8 2 5
t' Misc. Conduits&Conductors ;
I, as owner of the property, .will do the work and.the
structure is not intended or offered for sale (Section Other(See.Complete Fee Schedule)_ , O 1 1 3 $7
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY '
I hereby affirm that there is a construction lending agency
the Performance of the work for which this'perm'it is issuedfor
PERMIT FEE (Sub-Total.)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE.
Lender's Name
PERMIT ISSUING FEE j
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
hereby authorize representatives of this County to enter upon
the above-me Toned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
✓13—K�
ignatu of P ttee Date