HomeMy Public PortalAbout5312 MCCULLOCH AVE_Electrical__ ' WORKERS'COMPENSATION DECLARATION 20.0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have a certificate of consent to self 76A663
insure, or a certificate of Workers'Compensation Insurance, CE-806r, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified c p e eof (Sec. 3800�Lob.
�C..)) e'
Policy NoCompany JAL �iV� FOR APPLICANT TO FILL IN JOB /1
F1 Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS' l
�ertified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft $ — $ LOCALITY
LT
`�4toT.
n department. Multi-family Sq. Ft.. — NEAREST
Date-1 Applicant ��#• Residential Swimming Pools OWNER CROSS SORG/q�,
FIRM NAME I12J .s
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.— MAIL
COMPENSATION INSURANCE First 20 ADDRESS
IAVZ
(This section need not be completed if the work involved by 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'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
Date Applicant Total No. CITY Tel. No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP / PERMIT
Exemption, you should become subject to the Workers' Range— Heater—D.W. L APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven — Dryer W.M.— ADDRESS 1 C) ��
with comply with such provisions or this permit shall be Top FAU -r<-W.H. —
deemed revoked. CITY
Hood — Fan —Other— HI-idt.T10.
LICENSED CONTRACTORS DECLARATIONLICENSE OR �: 7 �:
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. — Class._
REG. NUMBE
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PR SE : >_
and Professions Code,and my lice se is in full force and effect. - I713 e�
License Numb
Size&Type HP, KW, KVA, or KVAR
Lic. Class Up to 1 Incl. FINAL `.HECK
Contractor
TOver 1 to 10 Incl. DATE Z� VALIDATION
TVDTn We, Date til
❑ ,Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY U
B.&P.C. for this reason Over 100 f _ Q
Services, Swbd., MCC&Ponelboards 01,101-1-i lilt
Date: 0-200 Amp. Under 600 V ® 7`;4:� ffii y'o�iZ
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION y
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits t�{�::T dz
Professions Code): .I}r' ��_v,-�
Ell, as owner of the property, will do the work and the Misc. Conduits 8 Conductors Rte.� ,.:.
Other See Complete Fee Schedule 33,07 =i`t^
structure is not intended or offered for sale(Section 7044, ( P )—
Business and Professions Code). - ; r_
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for t - '_50
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). CHECK
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE
1001
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 upon
t above-me tion, property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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01hatuIP Permitt ate ®'