HomeMy Public PortalAbout5323 WELLAND AVE_Electrical__ WORKER.'SCOMPENSATION DEC LARATION 776AS63t)Pw9/B9 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm 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'i ORKS BUILDING AND SAFETY DIV:
copy thereof(Sec.3800 Lab..C.) �, //� / /7;1.0
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Policy No. 6 V��ZCompany I�I� —� / FOR APPLICANT TO RLL IN I'J�pDRESS _23 . lu �• L '"Wl
�. Certified copy..Is hereby furnished. - EACH 'NO, FEE
New Resldential Bldgs.&P o LOCALITY
Certified copy is filed with the county building Inspection 1&2-Family,Sq. _ $ G NEAREST
/ department. Multi-family.Sq.Ft. )CROSS ST. ,e
g Z Residential Swimming Pools , ASSESSOR .
Data Applicant'
;,
t •:'_ IMAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. OWNER OR
_ I FIRM NAME
COMPENSATION INSURANCE First 20 s,,. �.;
MAIL, '
(This section need not be completed,if the work Involved by the Total No. Additional ' •'' ADDRESS
permit is for one hundred dollars($100)or less.).
'I certify that In the performance of the Iwork.for which this permit CITY - Toil..?k
is issued, I shall not employ'any person in any manner so.as to
become subject to the•Workers'Compensation Laws. Lighting FixturesFirst 20 PLAN CHECK
APPLICANT
Total No. Additional
• ADDRESS' ,
Date ' Applicant 150 F:tMA,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,-you should,become subject to the:Workers'Compensation 1 TO.10 INCLUSIVE EACH
provisions of-the Labor Code,.you must forthwith comply With such 11 TO 40 INCLUSIVE.EACH PERMIT _
provisions or this permit shall be deemed.revoked. 41 OR MORE BRANCH CIRCUITS EACH• APPLICANT
LICENSED CON15 OR 20A;208V TO 277V LIGHTING EACH
TRACTORS DECLARATION °. ADDRESS �? ►—
O
I hereby affirm that 1 am licensed under provis(ons of Chapter 9 /
(commencing with Section 7000)of Division 3 of.the Business and CITY � v LL Tel.No. U
Professions Code,anA.my license Is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE.OR
' $ Power Apparatus 6 Large Appliances REG.NUMBER 4( Class. L
Size Type DISTRICT NO. ,PRO ESSED BY V
License Number Lic.Class
�p s7 & HP :KW KVA,or KVAR �y
47 Over 3 to 10 Incl. FINAL A-
Cont ractor:.. ... - DateDATE
Over 10 to 50 Incl.' / Z
❑ I am exempt under•Sec. Over 50 to 100 lncl. Z'2 tP _VALIDATION'
4 Over 100 FINAL
B.&P.C.for this reason BY
Services,.Swbd.,MCC&Panelboards .'
i nate-0-200 Amp:Under 660 V"
Signature �= ' ;.-• 201=1007Amp..Under 600 V
❑' �' Over 1000 Amp.or Over 600 V "
Exemptiornfor Reg.Maint.Elect. -,
SINGLE FAMILY TTemp.Power Pole&Appurtenances _ }
HOME OWNER-BUILDER DECLARATION ''''-`
• 'I hereby affirm that I am exempt from the Contractor's License;Law. Sign with One Branch Circuit t '°R
i r
for the following reason(Section 7031.5, Business and Professions Additional Sion Branch.Circuitsfti;:! ;:,1,.'a3_,
_Code):. .. ,' .• M ,' '
❑ Misc.Conduits&Conductors
I,.as owner of the'property;will do the work and the structure _ _x .P�.-
Is not Intended or offered for sale(Section 7044, Buslness Oilier(See Complete Fee Schedule) !_ �_ y' : ? w
and Professions Code).
CHECK
CONSTRUCTION LENDING AGENCY ,
I hereby-affirm that there is a construction lending•agency for.the Sii a _={'D
performance of the work for which this permit.is issued(Sec.3097,. PERMIT'FEE (Sub-Total)
Civ.C.)
ECKING FEE
. PLAN CH _
Lender's Name -
PERMIT ISSUING FEE
Lender's Address
I certify that I have read Hits 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 arty for'inapecti urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF P NT OR AGE.
h.