HomeMy Public PortalAbout5947-5947 1/2 PRIMROSE AVE_Electrical__ CERS'�?OMi?ENZ40N DECLARATION' 76AB63 10t8l `1.4-1
1 �'d
'S ,• CE-808G APPLICATION FOR ELft ECTRICAL PERMIT
I fferiby efflrm•tpatr I have a certificate of consent to self insure,
or'a cwtificate of Workers'Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. Company' FOR APPLICANT TO FILL IN JOB p00,00
❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS ! 2
Y New Residential Bidgs.&Pools f
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft..aQ $ •b� _ $ 0 •.
LOCALITY �
NEAREST-
department. Multi-family Sq.Ft.. CROSS ST..
t ib Residential Swimming Pools. OWNER OR [/
Date Applicant 'FIRM NAME !T
CERTIFICATE OF EXEMPTION FROM.WORKERS'' . MAIL
Outlets:Recght— —
•' COMPENSATION INSURANCE � I—Li ' : } • , �ADORESS S� ✓�
First 20
(This section need not be completed if the work involved by the Total No. Additional CITY r Tel.No.
permit is for one hundred dollars($100)or less.)
I certify that.in the performance of the work'for which this permit PLAN CHECK
' is issued, I shall not employ an APPLICANT
p y y person ifI any manner so as to
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
�t8�1 Total No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTI E TO APPLICANT: If, after n king tis Certificate of PERMIT ea
Exemption,you should become subject to the Workers"Compensation Range_ Heater D.W. APPLICANT S � •.
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS&�Ve d4i
provisions or this permit shall.be deemed revoked: 5 Top — FAU _ W.H.
LICENSED.CONTRACTORS DECLARQTIQN Hood —. Fan _ Other_ CITY &(1_, 9YOTe(No. E .3 f gj
J Hereby affirm that I am licensed under provisions:of .Chapter 9 LICENSE OR Q ,f.��
(commencing with Section 7000)of Division S of,the Business and
Disp: — Room Air Cond.: REG.NUMBER. ` Class.Q _16111,
Professibne Code,and my license is in full force and effect: power Apparafus.&Large Appliances DISTRICT NO.� PROCESSEDZY
t/ Size&Type HP,KW,KVA,or KVAR +<
License Number l7S� r 'Lfc.Class Ld Up to 1 Incl: FINAL V
Over'1 to 10 Incl.
Contractor Date 71—"— — 7VALI TI N O
Over 10 to 50 Incl. FINAL
❑ I am exempt under Sec. Over 50 to 1.00 Inc. BY LL1
BAP.C.for this reason Over 100 N
Services,Swbd.,MCb&.Panelboards ► Z
0-200 Amp.Under 600 VFft
...
Signature 201 - 1000'Amp.Under 600 V
Over 1000 Amp.or Over 600 V '
❑ Exemption for Reg.Maint:Elect.
SINGLE FAMILY Temp.Power Pole-&Appurtenances 9.41,7 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuito 0 0 0 0 2
I hereby affirm that I am exempt from,the Contractor's License LAW
,for the following reason(Section 7031:5,Business and Professions Additional Sign Branch.Circuits
Code):. o ] 06,22
Fee Schedule)
❑, I, tinier of the property,will do the work and the structure Misc.Conduits&.Conductors — ° ° x
n 2 2 v
- is not intended or offered for sale (Section 7044, Business Other(See Complete '
and Professions Code). ► 0.10 9-88
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,
Civ,C.). PERMIT FEE (Sub Total) � 'a
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE y' 0
Lender's Address TOTAL FEE 'gf
I certify that I have read this application and state that the above. ,.
information is correct:I agreeto comply with all County ordinances
and. State laws regulating Electrical wiring, and hereby authorize
representatives of this County to.enter upon the above-mentioned
property for inspection purposes.
Lf o SEE.REVERSE FOR.EXPLANATORY LANGUAGE
G
Signature.of PerrnDtee if Date. I
1 `