HomeMy Public PortalAbout6031 PRIMROSE AVE_Electrical__ + ,r �, 3 w�rrh th COMPENSATION a TION DECLARATION CE-806 to/Bl APPLICATION �OR ELECTRICAL P R IT
insFe6or affcertif catf'esof Workers'tificate of Compensaf on ensurant to n elf CE-8066 I
or a certified copy.theieof(See'13800, Lob. C..)
COUNTY OF LOS ANGELES BUILDING AND SAFETY 'ul
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. EACH NO. FEE ADDRESS Q?a.l 1v
New Residential Bldgs. 8 Poo s �..
❑ Certified copy is filed with the county building inspec- 1 &2-Family,Sq. Ft. s•S $ — $ LOCALITY L
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Date Applicant OWNER OR Q�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw,_
FIRM
NAME
COMPENSATION INSURANCE ADDRESS g
(This section need not be completed if the work Involved by First.20 `
the permit Is for one hundred dollars($100)or less.) Total No. Additional CITY 8e' C e fi Tel. N $ d
I certify that in the performance of the work for which this PLAN CHECKAPPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS.
• It Total No. • Additional
Date_1 pplicant �LEGA CITY Tel. No.
Fixed Appliances Not Over 1 HP P RMIT olk IG gyro,
NOTICE T APPLICANT: If, offer making this Certi cdte of APPLICANT i
Exemption, you should become subject to the Workers' Range_ Heater_D.W.
Compensation provisions of the Labor Code, you must forth- Oven —Dryer _W.M. ADDRESS Lrh
with comply with such provisions or this permit shall be Top _ FAU _W.H. —
deemed revoked. CITY ` Tel. IVa.
LICENSED CONTRACTORS DECLARATION Hood _Fan _Other_ C" `
LICENSE OR
_ Room Air Cond.. j eYl�
I hereby affirm that I am licensed under provisions of Chapter 9 Dis P REG. NUMBER '�, Class.
(commencing with Section 7000).of Division 3 of the Business power Apparatus&Large'Appliances DISTRICT NO. -r PTS7,
�'
and Professions Code,and m license is in full f6rce and effect. C� /�
�y L i O Size&Type HP, KW, KVA, or KVAR- Vf(/r 0
License Number �IIsZ ;�_Lic.Class Up to 1 Incl. FINALDATE 0
p + Over 1 to 10 Incl. ��. VALIDATION �.
Contractor L a��I eg,4•Date.
L Over 10 to 50 Incl. FIN W
I am exempt under Sec. Over 50 to 100 Inc. BY n
B.&P.C. for this reason Over 100 Z
Date: Services, Swbd., MCC&Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V ;16 6a 2.A
❑ Exemption for Reg. MaineOver 1060 Amp. or Over. Elect. 600 V # 0,0 0 0 0 'z
SINGLE FAMILY Temp. Power Pole&Appurtenances "1 0 07524
HOME OWNER:BUILDER DECLARATION Sign with One Branch.Circuit o 0 - 7S245
I hereby affirm that I am exempt from the:Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code): 0 3 1 7-87
QI, as owner of the property, will do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ,
7044, Business and Professions Code).
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)
Lender's Name
PLAN CHECKING FEE
PERMIT ISSUING FEE
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-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permitt ' Date