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HomeMy Public PortalAbout5620 MCCULLOCH AVE_Electrical__ 1 . WORKERS'COMPENS.ATIONDECLARATION CE-8066 (2-80) APPLICATION FOR. E-806ELECTRICAL PERMIT C I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES``_.// � BUILDING AN'D_SAFETY insure,or a certificate of Workers'Corripensation Insurance,or _ a certified copy•thereof(Sec.3800,Lab.C.) ' 1 FOR APPLICANT TO FILL IN JOB Policy No. Company EACH.. NO. FEE. ADDRESS �(p� .. �• . New Residential Bldgs:&Pools 0 Certified copy is hereby furnished. 1•&2-Fainily.;Sq. Ft. $ — $ LOCALITY copy is filed,with the count building Multi-family Sq.Ft. NEAREST a DIt Ci Certified co y g inspection � 'CROSS ST department. Residential Swimming Pools OWNER OR FIRM NAME Date Applicant 'Outlets: Rec._LightSw. MAIL S� First 20 ADDRESS. CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. AdditionalCITY Tel No. } COMPENSATION INSURANCE d 1 PLAN CHECK 0 APPLICANT (This section need not be completed if the work involved V by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First io ADDRESS Total No. Additional O I certify that in the performance of the work for which this CITY Tel No. H permit is issued, I shall not employ an. Fixed Appliances Not Over 1'HP p p y y person in any manner PERMrr ` W so as to become subject to the Workers'Compensation Laws.• Range_Heater D.W. _ APPLICANT Oven _ Dryer.W.M._ ADDRESS�6 � Date Applicant Top _ FAU _W.H.,_ ` Hood _ Fan _Other_ CITY Tel No.(� NOTICE TO APPLICANT: If, after making this Certificate of Disp. _Room Air Cond._ ' LICENSE OR Exemption, you should become subject to the Workers' REG.NUMBER Class Compensation provisions of the Labor Code,you must forth- 1 Power Apparatus&Large Appliances DISTRICT NO. PR S BY with comply.with such provisions or this permit shall be deemed revoked. Size&Type HP,KW,KVi4,or KVAR, ©� Up to 1 Incl. FINAL , LICENSED CONTRACTORS DECLARATION Over 1 Over 10 Incl. DATE / 3 �2ft) VALIDATION tto o 6 50 Incl. 6 I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL BY 9 (commencing with Section 7000)of Diirision 3 of the Busi- Over 100 a.,.. ness and Professions.Code, and my license is in full force and effect. Services License Number Lic.Class. 0-200 Amp.Under 600 V 201-1000 Amp,Under 600 V Contractor Date Over 1000 Amp.or Over 600 V HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances ti I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit ' License for the following Beason- (Section 7031.5, Busi- Additional Sign Branch Circuits ness an rofessions Code): Misc.Conduits&Conductors ff`I, as dwner of the property, will do the work and the Other(See Complete Fee Schedule)— structure is not intended or offered for sale (Section 7044,Business and Professions Code). CONSTRUCTION LENDING'AGEN.CY =Z 7' A I. hereby affirm that there is a construction lending agency for the performance of.th'e work for which this permit is # 0 0 0 0 0 2 ,PERMIT FEE (Sub-Total) . issued(Sec.3097,Civ.C.). ` 2 0 0 9 5 0 Lender's Name ' PLAN CHECKING FEE (One-Fourth Permit Fee) Lender's AddressPERMIT ISSUING FEE 0 0 0 9.5 0 9 I certify that I have read this application and state that the , TOTAL FEE // 1 030-80 above ihformation is correct.I agree to comply with all County / ordinances and State laws regulating Electrical wiring, and hereby authorize repre ntatives of this County to enter upon thebove-mentioned.. rty-for.inspection purpo s. SEE'REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date i