HomeMy Public PortalAbout4959 MCCLINTOCK AVE_Electrical__ 'WORKERS'CL Adve S cerci DECLARATION .z000ivDPW 3is7 APPLICATION FOR. ELECTRICAL PERMIT
he'>�aby,affirm tkat 1 fiave a certificate of-consent to self c€� ,
insuzR, o?.Aa certificate bf Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
r`or ci_,6jSified copy thereof(Sec. 3800, Lab. C.)
"'Policy No. CompanyFOR APPLICANT TO FILL IN JOB "►�
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS ��.�IwOC
F]Certified copy is filed with the county building inspec- 1 &2-Family,'Sq. Ft. IZ13 $ — $ LOCALITY �tiQn department. Multi-family Sq. Ft. NEAREST
I CROSS ST. �iAw��
v '
Residential Swimming Pools
Date Applicant OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS' ' ZZ FIRM'NAME il Z2a
COMPENSATION INSURANCE Outlets:.Rec Light Sw. DDRESS
^� First 20 -y
(This section need not be completed if the work involved by Total IVa.-__I Additional . CITY . 1
the permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work-for which this APPLICANT
permit is issued,.I shall not employ any.person in any manner
so as.to become subject to the Wrkers'Compensation Laws. Lighting Fixtures 'First 20 I ADDRESS
L
Total'No. Additional .
Date Applicant t
NOTICE TO APPLICANT : If, after making this Certificate of Fized Appliances Not Over 1 HP CITY Tel. No.
PERMIT
Exemption, you should-become subject to the Workers' Range_ Heater—D.W. _ APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven — Dryer 1W W.M. ADDRESS
with •comply with such provisions or this permit shall be Top — FAU ' `!W.H.4W
deemed revoked. CITY Tel. No.
;LICENSED CONTRACTORS DECLARATION Hood — Fan —.Other_ _
Disp. Room Air Cond. _ l LICENSE OR
I hereby affirm that I am-I!censed under provisions of Chapter 9 M. NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. P CES BY >_
and Professions Code,and my license is in full force and effect. �q D-
Size 8 Type HP, KW, KVA, or KVAR (/� 0
License Number Lic. Class
Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE (_42,
VALIDATION
Contractor Date Over 10 to 50 Incl. FINAL y 0
❑ I am exempt under Sec. Over 50 to 100 Inc: BY u
B.&P.C. for this reason Over 100 , d
Services, Swbd., MCC&Panelboards Z
Date: i Z
0-200 Amp. Under 600 V —
Signature 201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V
EDExemptionfor Reg. Mairit.Elect. •{. .>
. I'iL•'_�a F
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances ^-_-`, iJ 01
-`�� 4
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit
Low for the.following reason (Section 7031.5, Business and Additional Sign Branch Circuits 1 ITEMS
Professions Code): j 1;1 Al �:y
as owner of the property, Misc. Conduits&Conductors
p p ty, will do.the work and the �s$��vli 110 a�IL'
structure is not intended or offered for sale(Section 7044; Other(See Complete Fee Schedule)—
Business and Professions Code). , y. ( tE a.ij
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 ) + i ar'`!�L
P P (Sub-Total
(Sec. 3097,'Civ. C.). rs.. a h ,r
PLAN CHECKING FEE 4-3 HIE 1a.J;
Lender's Name
PERMIT ISSUING FEE
Lender's Address C
I certify that I have read this application and statethat the TOTAL FEE
above information is correct. I agree to comply with all County
or ' antesand tate regulating Electrical wiring, and '
h re y a char ,' e r p solives of this County to enter upon
t ea o ntioo erty f&,inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
a ure o Per tte Date ®a