HomeMy Public PortalAbout5636 MCCULLOCH AVE_Electrical__ r ''WORKERS'COMPENSATION of consent
CEAs06 10/81 APPLICATION FOR ELECTRICAL PERMIT
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al hereby pifirrq that I have.a certificate of consent to self insure, •
.,or a'cd'rtificate of Workers' Cglnpensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.) ��'��
Policy No. Company�%-�G-- C= FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. EACH NO. FEE
❑ New Residential Bldgs.&Poo •
1 &2,-Family,Sq.Ft. Y'6 $ — $ LOCALITY Lsyy � C
❑ Certified copy is filed witq the county building inspection . — NEAREST
department. Multi-family Sq.Ft. CROSS ST. ,/ d
DateResidential Swimming Pools
Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM RK RS' MAIL
First 2
COMPENSATION INSURANCE Outlets:Ree Light— t 2 — ADDRESS
(This section need not be completed If the work.involved by the 0
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
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 this Certificate of Fixed Appliances Not Over ri HP PERMIT L
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ APPLICANT �G
provisions of the Labor Code,you.must forthwith comply.-with such Oven Dryer,_ W.M._ ADDRESS0 2• * Sim
provisions or this permit shall be deemed revoked. Top FAU _ W.H. _ CITY f Tel.No.7 J 4
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 8LICENS OR
(commencing with Section 7000)of Division 3 of the Business and Disp. — Room Air Cond: _ REG.NUMBER 14d 4 33 Class.e_,1'O
Professions Code,and my license is.in full force and effect. DISTRICT No. P SED BY
Power Apparatus&Large Appliances P d
/ Size'&Type HP,KW;KVA,or KVAR 6, 0 0
License Number Lic.Class ti'-/ Up to 1 Incl. FINAL V
Over 1.to 10 Incl.. DATE VALIDATION
Contractor. � J Date Over 10 to 50 Incl. TINA V
❑ I am exempt under Sec. Over 50 to 1DO.Inc. BY �y
Over 100 n-
B.&P.C.for this reason V)
Services,Swbd.,MCC&Panelboards ,. Z
are=
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 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):
Misc.Conduits&Conductors r
❑ I,as owner of the property,will do the work and the structureOther(See Complete Fee Schedule) _
is not intended or offered for sale (Section 7044, Business ,
and Professions Code). ;9 7 3 7.4 A
CONSTRUCTION LENDING AGENCY # 0000-02
I hereby affirm.that there'(s a construction,lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) 1 7234
Civ.C.).
PLAN CHECKING FEE o o o 7 2 3 4 1
Lender's Name !u 630-87
r PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL.FEE
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 `•
pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
lgna7tui &ee _ Date