HomeMy Public PortalAbout4813 RYLAND AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81 1,�1 [ f �����j ��) j [�®F7 EC`�j CAL DIERMOU
hereby affirm that I have a certificate of consent to self CE-806G !P'i119 lx" u u V FOR
CMCAL�
i sure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUBLDING AND SAFETY
r tif�'ec�,copy thereof (Sec. 3800, Lab
lYo.–��ompany FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. EACH NO. FEE ADDRESS
PY Y New Residential Bldgs. &Pools
$ _ $ LOCALITY T01
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. _ �/
tion epartment. Multi-family Sq. Ft. NEAREST
p Residential Swimming Pools OWN R OR
Dat gl Applicant 1
FIRM NAME
CER FICATE OF EXEMPTION FROM WORKERS' Outlets: RecLight Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
First 20
(This section need not be COmPleted If the work Involved by Total No. Additional CIN I. No
the permit Is for one hundred dollars($1180)or less.) PLAN CHECK
IJ
I certify that in the performance of the work for which this APPLICANT
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
Total No. Additional CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption, you should become subject to the Workers' Range_ Heater_D.W. — APPLICANT
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. — CITY Tel. No.
deemed revoked. Hood _ Fan _Other—
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 .DISTRICT NOPROCESSED BY
Power Apparatus&Large Appliances >�
and Professions Code;and my license is in full force and eff ct.
Si &TypeVA, or VAR ! V
License Numb Lic.Clas VW
o FINAL _
1 to 10 ncl. DATE f '1 ,� ( VALIDATION 00
Contractor Date ® FINAL ' ��1 tom• r V
Over 10 to 50 Incl.
❑ I am exempt under Sec. Over 50 to 100 Inc. BY ✓� •'� _; n�,�
IL
B.BP.C. for this reason Over 100 IL
Services, Swbd., MCC&Panelboards D
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp, or Over 600 V
Exemption for Reg. Mainf. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
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):
❑ I, as owner of theproperty, 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).
u I -•
CONSTRUCTION LENDING AGENCY
I hereby affirm.that there is a construction lending agency for i
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
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE s
above information is correct. I agree to comply with all County
ordinances and State lows regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned prop ry r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
P Signature of Per tt Date
i
76AG63 DBB 5A 11-50 .; APPLICATION FOR PERMIT
DEPARTMENT OF BUILDING AND SAFETY ELECTRIC
COUNTY OF LOS ANGELES
WILLIAM J. FOX, CHIEF ENGINEER
FOR APPLICANT TO FILL IN DISTRICT NO. GROUP ZONE PERMIT NO.
ELECTRICIAN .,
�+ _ RECEIVED BY READY FOR DATE ISSUED
ADDRESS 7�!T t�+� .G FIRST INSPECTION J /
CITY + / V TEL. NArhD:�z
COUNTY ICENSE NO. EXPIRBUILDING
PERMIT F E ADDRESS
FEE ®o
NUMBER EACH LOCALITY
LIGHT OUTLETS NEAREST,-If/
,t
RECEPTACLES CROSS ST._ _
WALL SWITCHES OWNER I,
TOTAL OUTLETS3' SC $ MAIL
ELEC. RANGES 2S ADDRESS
ELEC. HEATERS 25 CITY �I TEL. NO.
FIXTURES 5
1 HEREBY ACKNOWLEDGE THAT I HAVE READ THIS
MISC. APPLICATION AND STATE THAT THE ABOVE IS CORRECT
NUMBER OF LIGHT CIRCUITS AND AGREE TO COMPLY WITH ALL COUNTY ORDINANCES
NUMBER OF RECEPTACLE CIRCUITS AND STATE LAWS REGULATING ELECTRICAL WIRING.
MOTORS I CERTIFY THAT 1 POSSESS THE ABOVE VALID LOS
NUMBER HORSEPOWERFEE I ANGELES COUNTY LICENSE. OR I AM THE LEGAL OWNER
OF THE RESIDENTIAL PROPERTY DESCRIBED ABOVE.
NEW MVD. H OVER INC. EACH �J
1/2 a LEss $ .25 SIGNATURE OF �� /
1/2 2 .50 PERMITTEErL n
r
2 5 1.00 INSPECTION RECORD
5 to 1.50
15 50 2.50
50 200 5.00
20o Soo 10.00 J
500 1000 15.00 Z
OVER 1000 20.00
M. G. SET/FREE. CHANGER-HP (�
WELDERS:AC-KVA 0
GENERATORS-KW
TRANSFORMERS-KVA
TEMP. MOTORS (75%OFORIG.)
MOVED MOTORS (75%OFORIG.)
MISC.
SIGNS
NO. NO.TRANS. I APPROVALS
NO. NO. LAMPS
}
DATE INSPECTOR'S NAME
FOR EACH PERMIT:
WIRING $1.00 CONDUIT
FIXTURES $1.00 WIRING
SUPPLEMENTARY 50 FIXTURES
POWER
TOTAL FEE $ UTILITY CO. NOTIFIED
® FINAL ci/ /
Ci'