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Home My Public Portal About5528 MCCULLOCH AVE_Electrical__ WORKERS'COMPENSATION DECLARATION %'20-0019 DPW 3/87 1 hereby affirm that I have a certificate of consent to self 76,16,W APPLICATION FOR ELECTRICAL PERMIT , insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC'WORKS or a certified copy thereof(Sec. 3800,16b. C.) ` .Policy No. Company FOR APPLICANT TO FILL IN JOB Certified copy is.hereby furnished. -FEENew Residential Bldgs. &Pools EACH NO. ADDRESS $ $ LOCALITYr Certified copy is filed with the county building inspec- 1 &2-FamilY%Sq. Ft.— tion departm n Multi-family Sq. Ft. — NEAREST { Residential Swimming Pools W S RS Date ✓ ' Applicant FIRM NAME CERTIFICATE OF EXEMPTI N FROM WORKERS' Outlets: Recl–Light�Sw.� MAIL COMPENSATION INSURANCE ADDRESS (This section need not be completed if the work Involved by First 20 CITY Tel. No. the permit is for one hundred dollars($100)or less.) Total No. Additional ' I certify that in the performance of the work for which this' PLAN CHECK APPLICANT permit is issued, I shall not employ any person in any manner' Lighting Fixtures First 20 ADDRESS so as to becomes .je to the2orker . om a sation Laws. g g .Date01 Additional Applica 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. _ APPLICATION 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. — deemed revoked. Hood — Fan —Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. _ Room Air Cond. — Class. I hereby affirm that I am licensed under provisions of�Chapter 9 REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances I DISTRICT_NP. P C SED BY a and Professions Code,and my license is in full force and effect. Size&Type HP, KW, KVA, or KVAR ( hue ex O License Number _ Lic. Class Up to 1 Incl. FIRAL U Over 1 to 10 Incl. DATE VALIDATION Contractor - Date Over 10 to 50 Incl. U.. ElFINAL 1 am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 4. Dote: Services, Swbd..,MCC&Panelboards ° , Z 0-200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILYTemp. Power Pole&Appurtenances HOMEOWNER-BUILDER DECLARATION {.r r Sign with One Branch Circuit _ Z. I hereby affirm that I am exempt from the Contractor's License i Law for the following reason (Section 703.1.5, Business and Additional Sign Branch Circuits L."13 Profes ions Code): V1, as owner of the property, will'do the work and the Misc. Conduits&Conductors structure isnot intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ ® 50 —16 1.c l Business and Professions•Code.). F " � - CONSTRUCTION LENDING AGENCY CHIC •J I hereby affirm that there is a construction lending agency for i,HAN, .01, the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). i PLAN CHECKING FEEI �r; 89 / Lender's Namel'lrl–;i l 5,a3 ' Lender's thatAddress PERMIT ISSUING FEE _s�y _ Art (�f1182I certify that have read this application and state that the TOTAL FEE 670 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 f e above-mentions roperty for inspe on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ®1 Sign tura df Permittee Date 1 � I WORKERS'COMPENSATION DECLARATIONI 78-883 10/81 APPLICATION FOR ELECTRICAL PERMIT " �+ ' CE-806G I hereby affirm that I have a certificate of consent to self insure,, , or a certificate of Workers' Compensation Insurance, or a certified; COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab.C.) Policy No. Company I FOR APPLICANT TO FILL IN JOB Certified copy is hereby Furnished. EACH NO. FEE ADDRESS s L• New Residential Bldgs.&Pools ❑ Certified copy is filed With the county building inspection I 1 &2-Family,Sq.Ft. $ — $ i LOCALIT department. I Multi-family Sq.Ft. — NEAREST + Residential Swimming Pools CROSS ST. Date Applicant_ OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light—Sw.— MAIL COMPENSATION INSURANCE I ADDRESS !r (This section need not be completed if the work Involved by the First 20 permit is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.No. WHE I certify that in the performance of the work for which this permit� APP ICANT K is issued, 1 shall not employ any person in any manner so as to! become subject to the Workers'Compensation Laws. ; Lighting Fixtures First 20 ADDRESS Additional I Total No. I CITY Tel.No. Date Applicant I NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater. D.W. — APPLICANT L provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY Tel.No. I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class. (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSED BY Power Apparatus&Large Appliances Size&Type HP,KW,KVA,or KVAR License Number Lic.Class Up to 1 Incl. i FINAL ' Over 1 to 10 Incl. DATE/0 1 VALIDATION Contractor Date Over 10 to 50 Incl. LJ FINAL ❑ I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C.for this reason Over 100 N Services,Swbd.,MCC&Panelboards /� Z Date: 0-200 Amp.Under 600 V/V ?(!� S V M, Signature 201 - 1000 Amp.Under 600 V !' ❑ Exemption for Reg.MaiM,Elect. �Over 1000 Amp.or Over 600 V n 8 7 a 1 A SINGLE FAMILY Temp.Power Pole&Appurtenances # 0 0 0 0 0 2 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's License Law0 -29,50 for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits Code): a o o G 9 5 0 911*'I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors is not intended or offered for sale (Section 7044, Business Other(See C plete Fee chedule) and Professions Code). U V pGLrYI CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total) QV Civ.C.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address 1 certify that I have read this application and state that the above TOTAL FEE A � Sti information is correct.I agree to comply with all County ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of tPis County to enter upon the above-mentioned Xign or inspe i urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE f rm1 ee Date