HomeMy Public PortalAbout5414 A & B MCCULLOCH AVE_Electrical__ WORKERS'COMPENSATION DECLARATION .-76A663CEa APPLICATION 'FOR ELECTRICAL PERMIT
I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of Workers'Compensation Insurance,or
a certified copy thereof.(Sec.3800,Lab.C.)
FOR APPLICANT TO FILL IN JOB A�
Policy No. Company EACH NO. FEE ADDRESS�w (,
New Residential Bldgs Po.
D Certified copy is hereby furnished. 1 &2-Family,Sq.Ft ( $ — $ D LOCALITY
NEAREST
Certified copy is filed with the count building Multi-family Sq. Ft. CROSS ST -� �
P Y g inspection Residential Swimming Pools r�77
department. FIRM NAME LG
Date Applicant Outlets: Rec.—Light Sw. MAIL
First 20 ADDRESS (d V _ 1
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY�� 1 Tel No.�✓�G U�$�
COMPENSATION INSURANCE a
PLAN CHECK
(This section need not be completed if the work involved APPLICANT O
by the permit is,for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS V
Total No. Additional =
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. 0
permit is issued, I.shall not employ any person in any manner PERMIT (>
so as to become subject to the Workers'Compensation Laws: Range_Heater_D.W._ APPLICANT CV_ f, W
'/ DI Oven _ Dryer=W.M._ ADDR.ESSV.() �U� ca
CITY Tel N
-( dL
Date Applicants �� ` "' �- Top _ FAU _W.H.._ i _
' Hood — Fan _Other— S� G�
NOTI E T APPLICANT: If, after making this Certificate.of Disp. _Room Air Cond.— LICENSE OR c�
Exemption, you should become subject to the Workers' R b'C-REG.NUMBEU 6 Class C—
Compensation provisions of the Labor Code,you must forth- Power Apparatus&Large.Appliances DISTRICT NO. PROCESSED BY
with com'ply with such provisions or this permit shall bee&Te HPKWKVA
yp , , ,'or KVAR
deemed revoked. Size �,•40
' Up to 1 Incl. .
a-4__ZX
FINAL
,
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE Z7- 6Y VALIDATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
BY
9 (commencing with Section 7..000)of Division 3 of the Busi- Over 100 v
ness and Professions.Code, and my license.is in full force and
effect. Services
� x� 0-200 Amp.Under,600 V
License Number3r`�r`r%' Lic.Class C-%\1S> 201-1000 Amp,Under 600 V
Contractor�/Q�,Yt CA-6' Datee V -Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I. hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):' 2.2 0 6,0 A,
Misc.Conduits&Conductors
I, as owner oft the-property,ed o of do the work and the Other(See Complete Fee Schedule)— # o,o 0 0 0 2
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY 2 0 059, 10
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is S� 0 0 o S.9 1 11)
issued.(Sec.30.97 v.`L , PERMIT FEE (Sub-Total)
/ �[
0910-80
Lenders Name SS Y �--- 'PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address�b 0, •'1/(�L-,Q.� �-�/�
PERMIT ISSUING FEE ,
I certify that I have read this application and state that the iTOTAL 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 ,
the'above-mentioned property for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signed&of Permittee f grate `