HomeMy Public PortalAbout6017 ROWLAND AVE_Electrical__ WORKERS'COMPENSATION DECLARATIOI*,-.., �,. JbA 1 �
'I hereby affirm that I have a certificate of.consent to._seff 'CE- APPLMATION FOR'ELECTRICAL PERMIT 'I
insure, or a certificate of Workers'Compensation Insurance, COUNTY rOr(l05 ANGELES BUILDING AND SAFETY
or''a certified copy thereof-(Sec. 3800, Lab. C.) ,
.Policy No. Company FORA. l T TO FILL-IN JOB
;.I ❑ Certified copy is hereby furnished, New Residential Bldgs. $Ropes j EACH NO. FEE ADDRESS
Certified•copy is filed with the county building inspec- ' 1 $2-Fam1ly;Sq. Ft, $ $ t LOCALITY
tion department. Multi-family Sq. Ft. a `NEAREST
F.. CROSS.ST.
Residenticl Swimming Pools OWNER.OR
Date. Applicant
'1 FIRM NAME
CERTIFICATE'OF EXEMPTION FROM WORKERS' j m IL .
:COMPENSATION INSURANCE Outlets: Rec Light Sq,-
ADDRESSfQ
This section need not be completed eted If-the.work involved b Firstt 20 �--•
( P.lollarY Total No. CITY Tel. No.
undred dAddiradjal
the permit is for one hs(5100)or less.)
I certify that.,in the performance.of the work for which this PLAN CHECK
}� ,APPLICANT
permit i;;issued, I shall not-employ any person in any manner
so as to become subject:to the Workers'Compensation,Laws. Lighting Fixtures• First 2D ADDRESS .. ;
-Total No. itioe°I ) CITY Tel,No.
Dat pp t— Fixed Appliances ot Over 1 NP PERMIT
.I TICE TO APPLICANT: If,'after making 'this'Certificate oRange_ Heater_D:W,of Range—
APPLICANT
Exemption,you should '.become -subject to the Workers'
( Compensation provisions of the Labor Code, you must forth Oven _Dryer —W.M.—. ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood _ Fan _Other— CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
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 'DISTRICT NO. PROCESSED BY
and:Professions Code,and my license is in full force and-effect. IL
Size A Type HP, KW-, KVA, or KVAR- O
License Number Lic. Class• .'Up to f Incl. FINAL. V
Over 1 to 1:0 Incl. ' Z DATE —� VALIDATION
.Contractor Date , Over 10 to 50 Incl. - t
FINAL
El- i.am.exempt.under Sec. - Over 50 to'100 Inc: BY
IL
B.$P.C, for this reason- Over 100 . PA
Service's, Swbd.;MCC&Ponelboards
Dater 0'-200 Amp. Under 60.0 V
Signature 201 - 1000 Amp. Under 600 V
Over 1000 Amp.'or Over 600 V
❑' Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power..P,.ole$Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that l am exempt.from.the Contractor's License I
Additional Sign Branch Circuits
Law for the following reason (Section 7031.51 Business and
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 Other(See-Complete Fee Schedule)_ :=�9,9(i 6 A
7044, Business and Professions Code). U ► 4 c o 0 o'c
CONSTRUCTION LENDING.AGENCY ` '•
r7 F•
I hereby affirm that there is a construction lending agency for n•'c
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
.`
PLAN CHECKING FEE '
Lender's Name ® C ' 1'
_ 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 upop
.the above- ntioned property inspection purposes. SEE REVERSE FOR,EXPLANATORY LANGUAGE t
atureo ermittee / ate �+
'GA688 C!'-9oe 16/78) APPLICATION FOR ELECTRICAL PERMIT _
COUNTY OF LOS ANGELES BUILDING'AND SAFETY
FOR APPLICANT TO FILL IN. JOB. �j �^�
New Residential Bidgs.&Pools
EACH NO. FEE ADDRESS. (J / o'ce L/
1.&2-Fomily,Sq.Ft: $ ..025 — $ LOCALITY.
Multi-family Sq.Ft. :02 — NEAREST
Residential Swimming Pools 25:00 CROSS
T.OWNER.OR
FIRM NAME ��� .Cf9�1�lWr0�.�
Outlets:RecLight '� Sw: MAIL
First 20 .50 p ADDRESS. .1A�d1!7
'?Vs QWAAND
Total No. Additional .30 CITY ✓ XC_ C./ TeI..No �(y 3(,
- PLAN'• HECK
APPLI.
Lighting Fixtures First 20 50 ADDRESS,
Additional .30 .
Total No: CITY Tel.No.
Fixed Appliances Not Over 1 HP _ PERMIT-
Range—Heater_D.W.
APPLICANT
Oven—Pryer W.M.— ADDRESS : BW� J
Top _FAU W.H:_ CITY e TelN&WC—B�/�6Cf
Hood_Fan _Other_ LICENSE OR
Disp._Room'Air-Cond.- 2:50 REG.NUMBER Class, "
I HEREBY ACKNOWLEDGE THAT I HAVE READ.THIS.APPLICA- '
PowerApparatus.&Large Appliances TION'AND STATE THAT THE.ABOVE IS CORRECT AND AGREE TO
Size&Type HP,KW,KVA,or KVAR COMPLY WITH ALL. COUNTY,ORDINANCES AND STATE LAWS
Up to 1 Incl.
2.50 REGULATING ELECTRICAL WIRING:
I HEREBY-CERTIFY THAT'[AM:PROPERLY REGISTERED AND/OR
Over 1 to 10 Incl, 5.00, LICENSED AS RE601RED BY LOS ANGELES COUNTY AND ST' Es OF
Over 10 to.50 Irrcl. 12.50 CALIFORNIA OR THAT I AM THE.LEGAL OWNER OF TH OVE
Over 50 to 100 Inc:
25.00 DESCRIBED REI ENTIAL P ERTY.-
Over 100 40.00 PERMIT EE:
SIGNATUR �
Services FINF
. PROCE ED B g
0.200 Amp.Under 600 V 12.50
201-1000 Amp.Under 600 V 25,00
Over 1000 Amp,or Over 600 V 50.00 Z
O
Temp.Power Pole&Appurtenances 10.00 a.
Sign with.One Branch:Circuit 10.00 0
Additionnl.,Sign Branch Circuits 2:0.0 TION >. ^ !t, '; !�
ATION '�
Misc.Conduits&Conductors: 10.00 id ti o 0 o e 0 ;
Other(See Complete-Fee Schedule) ERSEE Z 2 o a `i 1,0,0
5
PERMIT FEE. /Sub-Total):
PLAN CHECKING FEE (One-Fourth Perm. it Fee) O
PERMIT ISSUING FEE '$7.00 00. �o
TOTAL FEE c ` QQ.
�.
INSPECTION.FI NALED W
date:Q�GS g By p�A.1?0!/0 Z®