HomeMy Public PortalAbout5759 ROWLAND AVE_Electrical__ WORKERS' I have a cerci DECLARATION 20.0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have a certificate of consent to self CE
insure, or a certifcate of Workers'Compensation Insurance,' COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof(Sec.-3800, Lab. C.)
Policy No. Company 4J I FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New,Residential Bldgs. 8 Pools EACH NO. FEE ADDRESSLig-
in
rRT Certified copy is filed a county building sVe 1 2-Family, Sq. Ft. �� $ — $ LOCALITY
tion d part ent. MbIti-family Sq. Ft. — NEAREST IF
CROSS ST. _
Date Applicant Residential Swimming Pools OWNER OR
'//�� Q FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�LightSAL MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed If the work Involved by �� First 20 CI Tel. No.
To)al No. Additional t t
the permit Is for one hundred dollars($100)or less.) _
I certify that in the performance of the work for which this APPLICANTK
permit is issued,I shall not employ any person in any manner i
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
����ee��, Additional UU
Date Applicant Total No._L_J� CITY Tel. No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W. APPLICATION�
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 2
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. `,� Cl! Tel. No. Q
LICENSED CONTRACTORS DECLARATION Hood Fan —Other_ '/6✓� �`
Disp. � Room Air Cond. _ LICENSE OR Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER ��
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRIC NO. PR717&
0
>_
and Professions Code,and my license is in full force and effect. y a
Size 8 T HP, KW, KVA, or KVAR (((///
License Number Lic. Class � J LUp to 1 Incl. FINAL n V
Over 1 to 10 Incl. DATE Ltf VALIDATION CC
Contractor Date O
❑ Over 10 to 50 Incl. F_
FINAL U
I am exempt under Sec. Over 50 to 100 Inc. BY W
a
B.BP.C. for this reason Over 100JA U)Date: Services, Swbd., MCC 8 Ponelboards ® �' f Z
0-200 Amp. Under 600 V - —
Signature 201 - 1000 Amp. Under 600 V 4
❑ Over 1000 Amp, or Over 600 V �hCC °v
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Tem Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION p' ITEMS
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits TOTAL 69 .20
Professions Code): ` ,
❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ ® t� IANGE
Business and Professions Code).
CONSTRUCTION LENDING AGENCY 3/ 10";I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) g' id i t L;;
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 3 �'
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 0 1 ,
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and I
hereby authorize represen atives of this County to enter upon
he above-ment'one r rty for inspection urp ses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dote