HomeMy Public PortalAbout5401 WELLAND AVE_Electrical__ •r;f'p WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 ADPL OC A VOON FOR ELECYR� /� L PERMIT Q
h>;reby affirm that I have a certificate of consent to self CE�G [�=0 u (bar`a1
"ii`asure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT, OF PUBLIC WORKS
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy N460 Company 6p— FOR APPLICANT TO FILL IN JOB Q 1 ,�,w '�•
❑Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS Ir/
ertified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.29, $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST ST. / Q
_ Applicant � Residential Swimming Pools
Date : OWNER OR
D�'✓
CERTIFICATE OF EXEMPTION FROM WORKERS' r FIRM NAME
Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE First 20 `' ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITY Tel. No.
the permit is for one hundred dollars($100)or less.)
PLAN 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. ILighting Fixtures First 20 ADDRESS
Additional '
Date Total No. CITY Tel.'No.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT ` .
Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS CAM�.
with comply with such provisions or this permit shall be Top — FAU W.H. —
deemed revoked. CITY a Tel. No.
LICENSED CONTRACTORS DECLARATION Hood — Fan —Other—
LICENSE OR
Dis — Room Air Cond. — Class.
I hereby affirm that I am licensed under provisions of Chapter 9 p REG. NUMBER ® -e'�
(commencing with.Section 7000)of Division 3 of the Business Power Apparatus&Large AppliancesDISTRICT NO. PROCESSED BY d
and Professions Code,and my license is in full force and effect. `
2 c -VQ
&Type HP, KW, KVA, or KVAR ` U
License N ber ® / Lic. Class Up to 1 Incl. FINAL I/Z®4=6( �/n Over 1 to 10 Incl. DATE _99-
�Q VAL ATION cc
Contracto Date Over 10 to 50 Incl. CCJ/ F-
❑ FINA r� W
I am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100 Il
Services, Swbd., MCC&Panelboards Z
Z
0-200 Amp. Under 600 V JE 0
Signature 201 - 1000 Amp. Under 600 V
ElExemption for Reg. ly int. Elect. Over 1000 Amp. or Over 600 V #118
SINGLE FAMILY ')Temp. Power Pole&AppurtenancesHOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ° 0
1 hereby affirm that I am exempt from the Contractor's License Additional Si n Branch Circuits
Law for the following reason (Section 7031.5, Business and g Q 7, 13-88
Professions Code):
❑ 1, as owner of the property, will do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Al 0,1 5.8 A
Business and Professions Code).
CONSTRUCTION LENDING AGENCY # o 0 0�0 0 'Z
1 hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) 1 S ( - 18638
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE � � 07. 13-88
Lender's Address 3
I certify that I have read this application and state that the TOTAL FEE
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
the above-mentioned prop y r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of P m' ee Date