HomeMy Public PortalAbout6333 TRELAWNEY AVE_Electrical_7/21/1993_service panel WORKER Save a certificate
Df consent
20ASM DPW(12 81) APPLICATION FOR ELECTRICAL PERMIT IJ
I hereby affirm That 1 here a carhhcete of consent to Bell meun 7°�e3
or a cartlrcattb of Worker a Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab C)
A N
Policy No Company FOR APPLICANT TO RU IN �QOB 7 �el e
❑ CeRifmd copy is hereby fumudled New Residential Bldgs 8 Pools NO EACH FEE LOCALITY ! al
❑ Certified copy is filed with the county,budding mepecuon 1 8 2 Family Sq Ft _ f f
department Multi family 9q FI NEMESTCROSS W LP D�
Date Applicant Residenual Srnmming Prods A SSORMAP BOOK p� PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERSOutlets Roc _
OVn R OR V P A�
COMPENSATION INSURANCE Light_Sw
Firm 20 LWL P
(This section need not be completed If the work Involved by the Total No Additional
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permit is for one humdred dollars($100)or less)
I certify that m the performance of the wo which this permit CITY Tel No
Is Issued I shall not employ any peMgZ2
PLµCHEM
become subject Io the Worker° Comp Lghtmg Fixtures Firm 20 APPLICANT Total No Additional
Date;'-,2 �� Appllcan ADDRESS
RESIDENTIAL APPLIANCES NOT OVER 3 K
NOTICE TO APPLICANT U alter making this Certificate of CITY Tel Nc
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply with such PAPPMLIC T V7 x (N p
provisions or this permit shall be deemed revoked Power Apparatus 8 Large Appliances
LICENSED CONTRACTORS DECLARATION Sao 8 Type HP KW KVA or KVAR ADDRESS 30
I hereby affirm that I em licensed under provisions of Chapter 9 Over 3 to 10 Incl
(commencing with Section 7000) of Division 3 of the Business and CfTI' 0 fel No +�B.�O
Professions Code and my license Is In full force and effect Over 10 to 50 Incl LICENSE OR �J� /� }
Over 50 to 100 Incl REO NIIkIBER �`� / y✓ a
Over 100 DISTRICT NO PR BY O
UnseceNum r s Uc Class p 8
Services Swbd MCC&Panelboards Q O
Con 'Q Date TV 0 399 Amp Under 000 V I FINAL
0
❑ I am exempt under Sec 1000 Amp Under 000 V 7,30-13 VALIDATION V
Over 1000 Amp or Over 800 V FINAL /J f1
B 8P C fa this reason BRANCH CIRCUIT FEES BY �.a�i�_ i
a.
Date 15A or 20A 120V Lighting or Racept Z
1 To 10 Branch Circuits
Signature 11 To 40 Breach Circular
E] 41 Or More Branch Cualb
ExemplKrn far Reg Mount Elect 15A 20A 209V To 277V Ljg=Br Cvcuts 4.
SINGLE FAMILY Temp Power Pole&AppurtenW e ances W
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit 1 ITEMS
I hereby affirm that 1 am exempt from the Contractor a License Law
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits TOTAL 63. 43
Code) Lfy LL - [
r_1I as owner of the property will do the work and the structure Min Conduits&Conductore CHECK 63.Td
Is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule)_ CHANGE .00
and Professions Code)
CONSTRUCTION LENDING AGENCY nnnn���n
I hereby affirm that there is a construction lending agency for the GM0—W01 I�7
/21/`73
per Cance of the work for which this permit Is issued(Sec 3097 PERMIT FEE (Sub-To* 0822 1 AM 7
:3*
CivPLAN CHECKING FEE
Lender a Name
PERMIT ISSUING FEE pulp Q
Lender a Address
I certlty that I have reed this appllmban and under penalty of purjury state TOTAL FEE 3
that the above mfurmatlon is coned I agree to comply with all County
a�dmend Siete law reguleting Electricalwinnp antlherebyeugrorva
I dmy to enter upon the ebo+emenuned property
QSEE REVERSE FOR EXPLANATORY LANGUAGE
/�F PERNIDEE DATE