HomeMy Public PortalAbout5632 1/2 MCCULLOCH AVE_Electrical__ WORKERS'COMPENSATION DECLARATION eE=
11 76A610/e1 APPLICATION FOR ELECTRICAL PERMIT
`i�hereby a�firm.that I Have a certificate of consent to self insure, � ca06osG
6�,a ceirtifhhte of Workers'"Compensation Insurance, or a•-certified COUNTY OF L•OS ANGELES BUILDING AND'.SAFETY
'fl ,
copy'thereof„(Sec.3600,Lab.C.) '-
Policy No. ' ` Company 5 r TIT QOM® FOR APPLICANT TO FILL IN JOB ADDRE b�.� LLoGy
Certified.copy is hereby furnished. New Residential Bldgs.&Po,oLls, EACH NO. FEE f
❑ 1 &2-Family,Sq,Ft.�R� $ _ $ LOCALITY d
Certified copy is filed with the county building inspection �
NEAREST
apartment. Multi-family Sq.Ft. CROSS ST. t IJ
Date _�'6 r Applicant Residential Swimming Pools OWNER OR
• * 1 FIRM NAME
CERTIFICATE OF EXEMPTION FROM WO KERS' MAILutlets:Ree—Light w.
O —S —
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work Involved by the First 20 CITY Tel.No.
,permit is fqr one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the'work for which this permit gppUCA�K
is issued, I shall not employ any person in any manner so as to
become subject to the Workers"Compensation Laws. Lighting Fixtures. First 20 ADDRESS
' Additional
Date �... Applicant 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'Compensation Range_ Heater D.W. — APPLICANT
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. _ CITY krWe&g ia C& Tel.No.. 2 * b
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Condi LICENSE OR Clsss/ O
(commencing with Section 7000)of Division 3'of the Business and REG..NUMBER (�
Professions Code,and my license is-in full force and'effect. `Power Apparatus&Large Appliances DISTRICT No. PR. S D BY
Size&Type HP,KW,KVA,or KVAR
License.Number .fl 6/ Lic.Class. 6 —/0 Up to 1 Incl.' FINAL C1
Over 1 to 10 Incl. DATE 7 VALIDATION
Contractor Date Over 10 to 50 Incl.
FINA
❑ .1 am exempt'under Sec. Over 50 to 100 Inc. 'BY W
BAP.C.for this reason Over 100 f IL
Services,SWbd.,MCC&Panelboards
Date:• 0 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑
Exemption.for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7.031.5,Business and Professions Additional Sign Branch Circuits
Code):
❑ 1,as owner of the property,will do the work and the structure Mism Conduits&Conductors
is not intended.or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code).
t .�
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) �„7'
Civ.C.).
PLAN CHECKING FEE r
Lender's Name G�9� C_!�G/L
PERMIT ISSUING FEE 0�0 PG
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE g 3 a
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
Signature of prmiftee Date