HomeMy Public PortalAbout5429 MCCULLOCH AVE_Electrical__ rORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I�ahereA.affirm that I have a certificate of consent to self CE-8066
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE 1�
5 — .
Certified copy is filed with the county building inspec- 1 &2-Family, q• Ft. $ $ LOCALITY � �NEAREST
tion department. Multi-family Sq. Ft. CROSS ST. / /j^
Residential Swimming Pools OWNER OR S `i
Date Applicant
FIRM NAME •
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
First 20 •y 'ey
COMPENSATION INSURANCE ADDRESS I / L✓� L !�
(This section need not be completed if the work involved by Total No. Additional CITY 1 Tel. No.67y-01�
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this A PPLALICANT�
permit is issued, I shall not employ any person in any manner
so as to become subject to the War Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY
NV
Date Applicant T
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. — APPLICANT
Compensation provisions of the Labor Code, you must forth- Oven — Dryer _W.M.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. — CITY Tel. No.
deemed revoked. Hood — Fan —Other_
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. r / PROCES BY
and Professions Code,and m license is in full force and effect. 1Q/
Size&Type HP, KW, KVA, or KVAR O
License Number Lic. Class FINAL (1
Up to 1 Incl. _/ f/'
Contractor Date at
Over 1 to 10 Incl. DATE 7 Gam//(/CJ, VALID- N
❑ Over 10 to 50 Incl. FIN u
I am exempt under Sec. Over 50 to 100 Inc. B /' rm
B.&P.C. for this reason Over 100
Date: Services, Swbd., MCC&Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Mainf. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits h
Law for the following reason (Section 7031.5, Business and 8
Professions Code):
Misc. Conduits&Conductors I o - 2550
MV
I, as owner of the property, will do the work and the o 0 0
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ® 121
7044, Business and Professions Code). -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for i
the performance of the work for which this permit is issued PER CLEZT7?feAL N/G (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE fJ
Lender's Address
I certify that I have read this application and state that the TOTAL FEE aia
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 ve-mentioned property for in ction purposes.
,. - GXK/;?^/�" � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee %%cDate