HomeMy Public PortalAbout5313 MCCULLOCH AVE_Electrical__ I . WW irm that
COMPENSATION DECLARATION 76MO DPW3/87 APPLICATION FOR ELECTRICAL PERMIT
I;hereby affirm that I have a certificate of consent to self •�� Q
ifisure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES 1 DEPT. OF.PUBLIC WORKS
or a certified copy
/thher�eof(Sec. 31800, Lab.
C..))
Policy No!XM��L Compony L/a �K/✓i[J FOR APPLICANT TO FILL IN JOB.
Certified copy is hereby furnished. New Residential Bldgs. &Pools. EACH NO. FEE ADDRE ®lr[
�]�(�/.Certifiied copy is filed with the county building inspec- 1. &2-Family, Sq. Ft. _
S 0 — $ LOCALITY
7`"tion department. — NEAREST F�
p Multi-family Sq. Ft. CROSS ST.
L.%CJ. UAL Swimming Pools OWNER OR
Date Applicant FIRM NAME
01 A COAL
CERTIFICATE OF EXEMPTION.FROM WORKERS' Outlets: Rec Light First 20 Sw._ MAIL �I
COMPENSATION INSURANCE ADDRESS
(This.section neednot be completed if the work involved by CI �1 Tel. No:.
the permit is for one hundred dollars(:100)or less.) Total No. Additional �Dtf/v)
I certify that in the performance of the work for which this PLAN CHECKAPPLICANT
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
• Addition I.
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION
Exemption, you should become subject to the Workers' Range—. Heater—D.W.
Compensatioh provisions of the Labor Code, you must forth- Oven — Dryer W .— ADDRESS b 61
with comply with such provisions or this permit shall be Top FAU W.H. —
deemed revoked. CITY
Hood Fan —Other—
„k Tel. No.29
9
LICENSED CONTRACTORS DECLARATION Dis LICENSE OR
1 hereby affirm that I am licensed under provisions of Chapter 9 p L Room Air Cond. — REG. NUMBER CJ IL Class. a
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. 'tkQGIMED BY �.}
and Professions Code,and m license is in full force and.effect. '
`� i 5 ,�O
//�� Size&Type HP, KW, KVA, or KVAR o _ U
License Numb ' Lic. ClassLLUp to 1 Incl. FINALj
DATE VALID)4 ]�ie '=
T�t�`t/ Over 1 to 10 Incl. p d r-
Contractor r •� �'
Ne Date L -` Z t}t j- m 5
Over 10 to 50 Incl. FINAL
I am-exempt under Sec.. Over 50 to 100 Inc. BY (. ' `}°� � �-=W
B.&P.C. for this reason Over 100 �_: :- 4
{.,hftNGE.. rte
n_�
Date:
Services, Swbd., MCC&Panelboards ® Z
0-200 Amp. Under 600 V —
Signature 201 - 1000 Amp. Under 600 V
El.
Exemption for Reg. Wlaint. Elect. Over 1000 Amp. or Over 600 V
1 B` =
tis=..
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION E
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 - };-� ��}2 Li}
Professions Code):
0Misc. Conduit
•I, as owner of the property, will do the work and the s&Conductors.
,_..
structure is not intended or offered for•sale Section 7044, Other(See Complete Fee Schedule)_ - �,1+
Business and,Professions Code).
�_
M: + g t C
CONSTRUCTION LENDING AGENCY }� �'-
I hereby.affirm that there is a construction lending agency for 10
the performance of the work for which this-permit is issued PERMIT FEE (Sub-Tqtal)
(Sec. 3097,Civ, C.).
-PLAN CHECKING FEE
Lender's Name 1
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 representatives of this County to enter upon
t bove-me tione roperty for inspection urposes.. -SEE REVERSE FOR EXPLANATORY LANGUAGE
Aid-
ature Pe tee a.e ®6