HomeMy Public PortalAbout5416 A & B MCCULLOCH AVE_Electrical__ WOQtKERS'COMPENSATIONDECLARATIO.IS ''
CE-806G (2-80) APPLICATION FOR 'ELECTRICAL PERMIT
I hereby affirm that I 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 / pI
Policy No. Company
New ResidentiaBldgsEACH O. FEE ADDRESS �(� uC
' l : Poo
ElCertified copy is hereby furnished. 1 &2-Family,Sq.Ft.6 $0011, — $ LOCALITY �� _/ 'CITE.
I
ElMulti-family Sq. Ft. NEAREST
Certified'copy b filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER O'R
FIRM NAME Ile
Date- Applicant. ,Outlets: Rec—Light Sw. MAIL O •'v
First 20. ADDRESS [1 In.1
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.. Additional CITY �,��j-e Tel.No. L� (r.7. 3
COMPENSATION INSURANCE
PLAN CHECK IL
APPLICANT O
(This section need not be completed if the work involved g U
Lighting Fixtures First 20
by the permit is for one hundred dollars ($100) or less.) ADDRESS
Total No. cc
O
I certify that in the performance.of the work for which this CITY Tel No. H
+ Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any person in any manner ` PERMIT //��� �+ W
so as to become subject to the Workers' Compensation.Laws. Range_Heater D.W._ APPL'ICANTSt_P ,h � �/f- p,
Oven' _ Dryer_W.M._ ADDRESSUj� -� U)
Dat U Appliban�c o � Top _ FAU _W.H.
Hood _ Fan _Other— CITY Tel No.
NOT CE O APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond— LICENSE OR,
Exemption, you should become subject to the Workers' REG.NUMB'EF30 `O)G Class C
,�
Compensation provisions of the Labor Code,you must forth- Power Apparatus&'Large Appliances DISTRICT NO. PR.00EBY'
with comply with such provisions. or this permit shall be Size&Type HP,KW,KVA,or KVAR
deemed revoked. ;5,of
Up to 1 Incl.
Over 1 to 10 Incl. FINALDATE
LICENSED CONTRACTORS DECLARATION / C1 / VALIDATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to.100 Inc. FINAL
9 (commencing with Section 7.000)of Division 3,of the Busi- Over'100 .� l—��°
ness and Professions-Code,and my license is in full force and
effect. Services -
License Number 39I-D 100 Lic.Class L) 0-200 Amp.Under 600 V
201-1000 Amp.Under 600 V
Contract E'Pcj-j fir U&- ate 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):
Misc.Conduits&Conductors
ElI, as owner of the property, will. do the work and the Other(See Complete Fee Schedule)— 2 2 O b 1 A
structure is not intended or offered for sale (Section
704.4,Business and Professions Code). # o o c o c 2
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction.lending agency 2 o 659, 1 0
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued(Sec.3097.rtsly(L). / fl �� 5 I �)
Lender's Name. 'C, 1�-� L) PLAN CHECKING FEE (One-Fourth Permit Feel
Lender's Address A tD(J V �A'�'�e'J/ 13 PERMIT ISSUING FEE 09. 1 —80
se nye fl A 'q11&'-7b
I certify that I have read this application and state that the TOTAL FEE 9 7,0
above information is correct.I agree t6 comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the abovb-mentioned property for inspection purp ses.
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SEE•REVERSE FOR EXPLANATORY LANGUAGE
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ligur
natPermittee to
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