HomeMy Public PortalAbout5634 1/2 MCCULLOCH AVE_Electrical__ WORKERS'COMPENSATION Dj=CLARATION n, 76A663 10/61 APPLICATION FOR ELECTRICAL PERMIT
+1.hereby affirm ttat I have a certificate of consent to self insure, CE-6066
or a `ktificate•of Workers''.Compensatioa Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. CompanyFOR APPLICANT TO FILL IN JOB YVt(ik/IWAPIer 0641"
Certified copy is hereby furnished. EACH NO. FEE ADDRESS .�
New Residential Bldgs.&Po
1 &2-Family,Sq.Ft. $ _ $ LOCALITY gi�yi��e CCertified copy is filed with the county building inspection NEARESTd(e.p�artment. Multi-family Sq.Ft. CROSS sr: L r v d
Date v-36_Applicant. Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM W KERSOutlets:Rec—Light—Sw.'--- MAIL
COMPENSATION INSURANCE I ti ADDRESS
First 20
(This section need not be completed.ff the work involved by the �;• t.., CITY, Tel.No.
peemit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit p LANE
K
r
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
Total No. Additional CITY Tel.No.
Date Applicant
NOTICE TO APPLICANT: If, after making thil Cert" Fixed Appliances Not Over 1 HP.. a of PERMIT
APPLICANT ® S
Exemption,you should become subjeot'to the Workers'.Compensation Range_ Heater D.W. _ /1PPIJCANT
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 Tel.No. Z
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_
I hereby, affirm that I am licensed under provisions of Chapter 9Disp. — Room Air Cond. Class.LICENSE OR CI—)d
(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. P ED BY
/�+y Size&Type HP,KW,KVA,or KVARL Q
License Number 4/1—]Llc.Class C,-/® Up to 1 Incl. FINAL
j Over 1 to 10 Incl. DA / C
Contractor Date & —3 c a ' VALIDATION
Over 10 to 50 Incl.
FI. W,
0 I am exempt un r Sec. Over 50 to 100 Inc. gY
B.&P.C.for this reason Over 100 CO)
„ Services,Swbd.,MCC&Panelboards
Date: 0-200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under.600 V
F1 Exemption
1000 Amp.or Over 600 V ,
Exemption for Reg.Maint.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 Law Additional Sign Branch Circuits
for the following reason(Section 7031.5,Business and Professions
Code): a U
0 +
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 Complete Fee Schedule) _ ► 0 b 3 0.0 87
and Professions Code).. f
CONSTRUCTION LENDING AGENCY GF��y
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)
Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE Q.
'Lender's Address p/�
I certify that I have read this application and state that the above TOTAL FEE d
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
prope y for inspection purposes.. SEE REVERSE FOR EXPLANATORY LANGUAGE
V1�� rV 7 1
Signature oVerriffittee 17�Date