HomeMy Public PortalAbout6019 PRIMROSE AVE_Electrical__ I hereby affirm'WORKER'S
RfTatR h COMPENSATION
e a certificate lV OEconsentLlOto self insure, 7BA663 DPW(72-91) APPLICATION FOR ELECTRICAL PERMIT ll
or a certificate of Worker's Compertsation.Insurance,or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy th.ere$f(Sec.3800 Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN. JOB
Certifie(1 copy is hereby furnished. NO. EACH FEE
ADDRESS V1�
New Residential Bldgs.&Pools LOCALITY
❑ -Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. — $ $ NEAREST
department. Multi-family Sq.Ft. — CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK _ PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:ReLightSW. OWNER.OR �• `
COMPENSATION INSURANCE FIRM NAMEQ
(This section need not be completed if the work Involved by the First 20 MAIL
permit Is for dna hundred dollars(5100),or less, Total No. Additional 'ADDRESS
) '
I certify that in the performance of the work for which this permit CITY Tel.No.
is issued, I shall not employ any person in any manner so as,to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
` t Total No. Additional ADDRESS
Date 1Zplicant L� RESIDENTIAL APPLIANCES NOT OVER 3 HP..
NOTICE TO APPLICANT: If, after making this ertificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT t
provisions or this permit shall'be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS Z12f 06160C11 I
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. ` q
(commencing with Section 7000)of Division 3 of the Business and CITY d. ( Tel.No.
Professions Code,and my license Is in full force and effect. Over 10 to 50 Incl. }
LICENSE OR /
Over 50 to 100•Incl. REG.NUMBER 4:2.4 Cleae.�j 6 0.
Over 100 Q
License Number - Lie.Class .. .C DISTRICT NO. PRO SED BV Q V
Services,Swbd.,MCC&Panelboards
.�-f _ FINAL
Contractor L 6 F�IL��Date. Z— 0-399 Amp.Under 600 V DATE o
❑ I am exempt under Sec. 400-1000 Amp:Under 600 V �Zr
VALIDATION
Over 1000 Amp.or Over 600 V FINAL a
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
15A,or 20A,120V,Lighting or Recept. - Z
Date: _
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V.Ughting Br.Circuits n.
SINGLE FAMILY Temp.Power Pole&AppurtenancesJL
� ,�.
HOME OWNER•BUILDER DECLARATION Sign with One Branch Circuit 'f„`'�`I'� _
I hereby affirm that I am exempt from the Contractor's License'Law
for the following reason (Section 7.031.5, Business and.Professions Additional Sign Branch Circuits y: j3 .190.65
Code): 1 y e w�,"
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 0
Is not'intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) , TOTAL
"nB.§:Ck.65
and Professions Code). iit+s�; y
e: l:•. 1F3al.•til
CONSTRUCTION LENDING AGENCY Ta
`HAA -L .J_1.
1 hereby affirm that there is a co.n..sfruction lending agency for the u; +31-
performance of the work for which this permit Is issued(Sec.3097., PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE ) (y.3i 3.j} j 1'1/'1 A Ir e;
Lender's Name "3� r e
PERMIT ISSUING FEE lv �: I'; 1 AM•3 Yt _.1'I05
Lender's Address !�6
I certify that I.have read this application and under'penalty of purjury state TOTAL FEE O�
that the above Information is correct. I agree to comply with all.County
ordinances and State laws regulating Electrical wiling,,and hereby authorize
representatives of.this County to enter upon the above-mentioned property „
for inspectio : urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
v
DATE
SIGNATURE PERMITTEE - '