HomeMy Public PortalAbout6335 SULTANA AVE_Electrical__ • r �h�flRKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL RICA PERMIT
�firm that I have a certificate of consent to self CE-BO6G a°^ L.
re; r a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereoof (Sec. 380 Lab. C.)
Policy NoPL t --' FOR APPLICANT TO FILL IN JOB
S LJ 40L
Certified co is hereby furnishe I EACH NO. FEE ADDRESS
PY Y N w Residential Bldgs. 8 Pools
Iry- Y� q•
1 &2-Family, S Ft. $ — $ OCALITY -� , -
Certified copy is filed with the county building inspec- —
tN tion department. Multi-family Sq. Ft. NEAREST
Residential Swimming Pools CROSS ST.
Date 4 '-F Applicant Qegn&C&u - L OWNER OR
FIRM NAME A
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.�_ MAIL
COMPENSATION INSURANCE ADDRESS
neenocompleted if the work involved b First 20
(This section need be com P y Total No. Additional CITY Tel. No.
the permit is for one hundred dollars($100)or less.)
PLAN CHECK
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'Compe:��
Lighting Fixtures First 20 ADDRESS
(�� Total No. Additional CITY Tel. No.
Date - pplicant s ` o joy Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
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 ,�
with comply with such provisions or this permit shall be Top _ FAU —W.H. — I JW Az P
deemed revoked. Hood _ Fan _Other— CITY Tel. 1V0.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG.NUMBER bass.
(commencing with Section 7000)of Division 3 of the Business ppDISTRICT NO. PROCESSEDZ M
Power Apparatus 8 Large Appliances .-
and Professions Code,and my license is in full force and effect.
s Size 6 Type HP, KW, KVA, or KVAR (!
License Number �c2fl .� Lic. Class e L® Up to 1 Incl. FINAL
e� -date '® Z,� ? I--
Over 1 to 10 Incl. DATE Z_ / VALIDATION
Contractor �/
❑ Over 10 to 50 Incl. FINAL W
I am exempt under Sec. Over 50 to 100 Inc. BY
B.BP.C. for this reason Over 100 3 0 5 9 A
Date: Services, Swbd., MCC 8 Panelboards +L+
-# 0 0 0 0 0
0 -200 Amp. Under 600 V o o 8 2 6
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V o 0 o 8 2 6 2 5
ti
SINGLE FAMILY Temp. Power Pole&Appurtenances i a 0 3-8 5
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 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 PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name D
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 preEnt.otives of this County to enter upon
th above entio edrty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permute Date