HomeMy Public PortalAbout5634 MCCULLOCH AVE_Electrical__ WORKERS COMPENSATION DECLARATION „ 76A663CE406 10/81 APPLICATION FOR ELECTRICAL PERMIT
' I hereby affirm that'I have a certificate of consent to self insure, CE=sosG
pr a tbertiftate of,Wofkers' Compensation Insurance,.or a certified COUNTY'OF LOS ANGELES BUILDING AND SAFETY
'copy thereof(Sec.3800,Lab.C.)
Policy No. Company eT 1�^ FOR APPLICANT TO FILL IN JOB ` C
Certified copy is hereby,furnished. EACH NO. FEE ADDRESS
New Residential.Bldgs.&.Pools p
❑ $ _ $ LOCALITY
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft: �L
department. Multi-family Sq.Ft. — NEAREST /n
., Residential Swimming Pools ` CROSS ST v V
Date 2 ` 'Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM RKERS' Outlets:Rec—Light_Sw.— MAIL
COMPENSATION INSURANCE ADDRESS
(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.
I certify that in the performance of the work for which this permit PLAN CHECK.
APPucANr _
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
1. Total No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not.Over 1 HP PERMIT
NOTICE TO APPLICANT. If, after making this Certificate. of APPLICANT F. L�L
Exemption,you should become subject to the Workers'•Compensation Range_ Heater D.W. _
provisions of the Labor Code,you must forthwith,comply with.suchOven _ Dryer_ W.M._ ADDRESS ; 2,
-.provisions or this permit shall be deemed revoked. Top _ FAU _ W.H.._ CITYeA Tel.No.6A. �+4
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 LICE OR
(commencing with Section 7000)of Division 3 of.the Business and Disp. — Room Air Cond. Class. r (�
REG.NUMBER L
Professions Code,and my license is in full force and effect. DISTRICT NO. P ED BY �--
Power Apparatus&Large Appliances c96? �
Size&Type HP,KW,KVA,or KVAR 1` � Q
License Numb. -1c.Class IL
C^'O Up to 1 Inol. FINAL V
G—Z6,••d / Over 1 to 10 Incl. DATE VALIDATION
Contractor Date Over 10 to 50 Incl.
FINA 8
❑ I am exam I der Sec.. Over 50 to 100 Inc. BY a
B.&P.C.for this reason Over 100 Cl)
Services,Swbd.,MCC&Panelboards Z
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 7031.5,Business and Professions Additional Sign Branch Circuits
Code):
❑ I,asn Misc.Conduits&Conductors
owner of the property,will do the work and the structure _
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code).
;1737,2A
CONSTRUCTION LENDING AGENCY # o 0 0•o,o 'Z
I hereby affirm that there is a construction lending agency for the 4 o 6 a 9 4
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total)
Civ.C.). o,o 068,941
PLAN CHECKING FEE
Lender's Name 0 630-87
PERMIT ISSUING FEE �O
Lender's Address ` G
I certify that I have read this application and state that the above TOTAL FEE (p O
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 r inspection pur es:
(, SEE'REVERSE FOR EXPLANATORY LANGUAGE
Si ature of mitt a Date