HomeMy Public PortalAbout5310 WELLAND AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20.0019 DPW(12.91) ®®LICq�TO® ��1R ELECTRICAL PERMIT
78A663 41'fi>�° b`� -aid
I herebyaffirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance,or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.) ' .�•
P❑OIICy NO. Company FOR APPLICANT TO FILL IN ADDRESS /
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH. FEE
$ $ LOCALITY 'exp
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Residential Swimming Pools ASSESSOR
Date Applicant MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. FIRMOWN NAME ,
COMPENSATION INSURANCE
First 20MAIL
(This,section need not be completed if the work Involved by the Total No. Additional ADDRESSsn
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit .i Cl!A
Tel.No.
Is issued, I shall not employ any person ' any manners as to PLAN CHECKIY
become sub ct to the Workers'Compens on Laws. Lighting Fixtures First 20 APPLICANT
Total/No. Additional ADDRESS
Date. Applicant E3�ETVfi AL A LIA S&&N015T OVER 3 HP.
NOTI T APPLICANT: If, after In n this tificate of D CITY Tel.No. 0-�a 9
Exem ion,you should become subject tote Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code,you must forthwith comply with such PERMIT cA
p y Power Apparatus&Large Appliances APPLICANT c , J
om
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS d
I hereby affirm that I am licensed under provisions of Chapter 9 1 Over 3 to 10 Incl.
(commencing with Section 7000)of Division 3 of the Business and CITY Tel.No. 7
Professions Code,and my license Is in full force and effect. Over 10 to 50 Incl. LIC SE OR a��
Over 50 to 100 Incl. REG.NUMBER rd� Class. /� a
I
C-1 0 Over 100 DISTRICT NO. P O SED BY O
Licen a Number Lic.Class �Q G U
Services,Swbd.,MCC&Panelboards a
0-399 Amp.Under 600 V FINAL O
Contractor � Date � DATE
• I 400-1000 Amp.Under 600 V e-4 y am a pt nder Sec. VALIDATION V
Over 1000 Amp.or Over 600 V V FINAL a
B.&P.C.for this reason BRANCH CIRCUIT FEES
Date: 15X,or 20A,120V,Lighting or Recept. Z
i
I 1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
41 Or More Branch Circuits
❑ Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits i i T
SINGLE FAMILY Temp.Power Pole&Appurtenances I t
HOME OWNER-BUILDER DECLARATION `:it f I SN
h Ci
B
ith One Branch Circuit S_
I hereby affirm that I am exempt from the Contractor's License Law Signwr.1,r,l1V 3� {c
for the following reason (Section 7031.5, Business and'Professions Additional Sign Branch Circuits ;'Ir_=1s4 -�O`
Code): , CPA
❑•
Ir 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)
and Professions Code). K s r• t : L"I1
CONSTRUCTION LENDING AGENCY i F•
1 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 i /
PERMIT ISSUING FEE !�
Lender's Address
l certify that I have read this application and under penalty of purjury state TOTAL FEE & t/0s
that the above Information is correct. I agree to comply with all County '
ordinances and State laws regulating Electrical wiring,and hereby authorize
representat s of this County to ant upon the above-mentioned property +
Wforinn purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ER EE E•
P
76A663-CE306 9-64 APPUCf>�/ UPON FOR ELE� 1 PERMIT
• � TT �'
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUILDING //1 LV ) f
BUILDING AND SAFETY DIVISION ADDRESS �J lfG+
JOHN A. LAMBIE. COUNTY ENGINEER
COLEMAN W. JENKINS, SUPT. OF BUILDING LOCALITY �'"LL.•
NEAREST
FOR APPLICANT TO FILL IN CROSS ST.
RECEPT. TOTAL NO. EACH FEE `/ j� ,y C
OUTLETS FIRST 20 /!E.20 $ i® OWNER ���/✓
LISHT L+ MAIL J �Q�
.y OA VER .1O 9 � ADDRE88 / C4 ,+
SWITCH OVER 2O : '[ rr
4
TOTAL CI � C L NO.
TEL.
LIGHTING I F1R5T20 J .EO � TY 7G / T
FIXTURES } �� - ADD'L 1O ELECTRICIAN C��jG �+
OVER 20 (N /f� LVL
���� )JVL �p
RANGES CLO.DRYERS WTR.HTRB. 1.00 ® ADDRESS / •! i"r J9 Llf'V✓o
GARB.DISP. STA.COOK A ' eW .7f7ff IZ
CITY �/�j TEL.NO.
DISHWASH. AUTO.-WASH. STATE
SPACE HTRS. STA.APP.(:/s H.P.MAX.) .50 LICENSE NO. Alf
f�
MOTORS:+ OVER NOT OVER H.P. DISTRICT N G P ZONE P O
/9r. O 9 1.00 }I `
I��
1 3 1.50 INSPECTION R_9CORD
3 8 2.00 D-
O
8 1 s2.50 V
15 so 3.00
so 100 5.00 OR
U
SIGNS: NO.TRANS. d
NO.LAMPS y
_z
SERVICE 0.600V•NoT OVER 200A 1.00
SERVICE 0-600V-OVER 200 A. 2.00
SERVICE OVER 600V 5.00 }
MISC.
PERMIT ISSUING FEE 2.00
SUPPLEMENTARY PERMIT ISSUING FEE 1.00
TOTAL FEE S
1 HEREBY ACKNOWLEDGE THAT 1 HAVE READ THIS APPLICATION APPROVALS DATE INSPECTOR'S SIGNATURE
AND STATE THAT THE ABOVE IS CORRECT AND AGREE TO COMPLY CONDUIT
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING
ELECTRICAL WIRING. WIRING
1 HEREBY.CERTIFY THAT 1 S PROPERLY REGISTERED AND/OR FIXTURES
` U
LICENSED AS REQUIRED M LOS ANGELES COUNTY AND STATE OF
CALIFORNIA OR THAT 1 AM THE GALg0T.ER OF, AND INTEND TO
RESIDE IN,THE ABOVE DESCRIB RESL PROPERTY POWER
SIGNATURE UTILITY CO.NOTIFIED I--,?
OF PERMITTEE FINAL
LI JOSEPH C.
CK MOO CASH SUPERVISINGG ELECTRICAL
TRICAL ENGINEER
LA00 2 6 0 9 JUN 14 2 D 2 0.8 0