HomeMy Public PortalAbout5657 MCCULLOCH AVE_Electrical__ WORKERS'COMPENSATION DECLARATION M-0319DP.W3/87 APPLICATION FOR EL -CTRICAL PERMIT O
I hereby affirm that I have'a certificate of consent to self CES
insure, or a certificate of Worf2er"s'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof(Secu3800,'Lab. C.)
Policy No. Compd� FOR APPLICANT TO FILL IN JOB C/ c– 7 Q/� /
Certified co is hereby furnished. EACH NO. FEE ADDRESS 5�4 / _6,.IOC
PY Y -New Residential Bldgs.�&Pools
LOCALITYr
EJCertifiedcopy is filed with .the county building inspec- 1. &.2-Family, Sq. Ft. $ ._ $ e ��
tion department. Multi-family Sq: Ft. NEAREST( U CROSS ST. � � Q14k
Residential Swimming Pools OWNER OR
Date Applicant (FIRM NAME u
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light ' Sw._ jMAILC n
COMPENSATION INSURANCE (!ADDRESS 5('9S7
First 20
(This section need not.be cbmpleted if the work involved by Total No. Additional;' CITY ex le Ci Tel..No.818 (^
the permit is.for-one hundred dollars;(5100)or less.) . , i =
IPLAN CHECK.
I certify that in the performance of the work for which this APPLICANT
permit 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
Date Applicant Total No. Additional CITY Tel No.
NOTICE TO APPLICANT: If, after 'makingthis♦Certificate of ! Fixed Appliances Not Over 1 HP PERMIT
,APPLICATION .
Exemption, you should become subject to the Workers' Range— Heater—D:W. —
Compensation,provisions of the Labor Code, you must forth- Oven. --Dryer —W.M.— 1ADDRESS 42.0,r�/
with comply with such provisions or this permit shall'be Top — FAU W.H. —
deemed.revoked. - CITY ems, e C 4�% Tel. No., <e
Hood — Fan —Other_
LICENSEDCONTRACTORS DECLARATION LICENSE OR
Disp. _ Room Air Cond. — Class.
I hereby affirm that I am licensed under provisions of Chapter REG.NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances ,DISTRICT NO. P O SSED BY d
and Professions Code,and my license is in full force and effect. jy
Size&Type NP, KW, KVA, or KVAR V. 6 U
License Number tic. Class Up to 1 Incl. �FIIVAL
IM
Over l to 10 Incl. DATE 1 .I VALIDATION
' Contractor Date Over 10 to 50 Incl. 'FINAL U
❑ I am exempt under Sec. I' Over 50 to 100 Inc. )BYg!;E:�t W
B.&P.C. for this reason Over 100 ' a-
j Services, Swbd., MCC&Panelboards Z
Date: _
0-200 Amp. Under 600 V
Signature il' 201 - 1.000 Amp. Under 600 V
❑ Over 1000 Amp, or Over 600 V
Exemption for Reg. Maint. Elect. � I -
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
I
Sign with One Branch.Circuit �
.I hereby affirm that I am exempt from the Contractor's License i a
Law for the.following,reason (Section 7031.5, Business and Additional Sign Branch Circuits
Profe ons Code):
I, as owner of the property, will do-the work and the 'I
Misc. Conduits&Conductors ( i 1TEM
structure is not intended or offered for sale(Section 7044, Other(See Complete Fee Schedule)_ ® :Irl€� 31 . 00
Business and Professions Code).
CONSTRUCTION LENDING AGENCY I CHrEX zol.11':
I hereby affirm that there is a construction lending agency for '.i� Mtj� ,I_tJ
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.j.
PLAN CHECKING FEEIlf 41–llllCll of 7 j
Lender's Name
• � PERMIT ISSUING FEE
Lender's Address
''�94 S i 11!3!J a J.
I certify that I have read this application and state that the TOTAL FEE i
above 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 i
•th v ori operty for.inspection purposes. I SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
S. .