HomeMy Public PortalAbout5405 WELLAND AVE_Electrical__ '•r` WORKERS'COMPENSATION DECLARATION 20.0019 DPW 3/87 O
..F� I hefeby affirm that I have a certificate of consent to.self 7"663AP° LOCA700N FOR ELEO ° MAL PERMIT
insure; or a certificate of Workers'.Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certyfiW rz-thereof(Sec. ny Lqb!C.)r� FOR APPLICANT TO FILL IN JOB /. .
Policy Certified
ff.• Company 3 ADDRESS � ®� w frL
❑Certified copy is hereby furnished. New Residential Bldgs. Pols EACH NO. FEE
LOCALITY
❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. � $ _ $
tion department: Multi-family Sq. Ft. NEAREST
CROSS ST. w
�' " Residential Swimming Pools OWNER OR
Date Applicant y FIRM NAME 0w
CERTIFICATE OF EXEMPTION FROM WRKERS' Outlets: Rec Light Sw._ a MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work.involved by First 20 CITY Tel. No.
Total No. Additional
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. Lighting Fixtures First ti ADDRESS
Additional
Date A licant Total No. � CITY Tel. No4svoa Applicant— Fixed Appliances Not Over 1 HP PERMIT /NOTICE TO APPLICANT: If, after making this Certificate of 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.— ADDRESSwith comply with such provisions or this permit shall be Top — FAU —W.H. —
CITY Tel. No
deemed revoked. � c ® L
Hood — Fan —Other—
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. — Room Air Cond. — REG.NUMBER 7 Class.
1 hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY a
and Professions Code,and my license is in full force and effect. t/ o O
Size&Type HP, KW, KVA, or KVAR [ d
License Number –/ Lic. Class ` Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE VA ATION 0
nfract r Date Over 10 to 50 Incl. FIN U
❑ I am.exempt under Sec. Over 50 to 100 Inc. BY UJ
B.&P.C. for this reason Over 100
�+ Servicesad M , Swbd., MCC& Ponelboards D Z
M.-
0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V 2S 0 1 a 4 A
El Exemption
1000 Amp. or Over 600 V # 2
Exemption for Reg. aint. Elect. o �0 0 0 0
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I •o - 73.82
1 hereby affirm that I am exempt from the Contractor's License =
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits o 0 0 7 3,82 0
Professions Code): 18 8
Ell, as owner of the property; will do the work and the
Misc. Conduits&Conductors Q 7.1 3.
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ D ,
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I 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)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE ,l
Lender's Address TOTAL FEE a
I certify that I have read this application and state that the 113 ,
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 obo -mentioned rt for inspections purposes. �s450"
SEE REVERSE FOR EXPLANATORY LANGUAGE
s l� ®s
gnature o er?0 ee Date