HomeMy Public PortalAbout5407 WELLAND AVE_Electrical__ r3• �
WORKERS'COMPENSATION DECLARATION 20M. 1.9 cPw 3,167 /p� 0 0n �5� 0 0 \
id'fi'esieby affirm that I have a certificate of consent to self CE-8066 APPLEC AUEOO N FOR ELECUR�CAL PERMIT
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certifi d copy Ther f (Sec. 3800, bb. C.) ' A
Policy No G mpany + �� FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New Residential Bldgs. Pols EACH NO. FEE ADDRESS %®� lisnfiy.
❑Certified co is filed with the count building inspec- 1 &2-Family, S Ft. , $ — $ LOCALITY
Py y g p y� q � � • NEAREST IL 1,J
tion de artment. Multi-family Sq. Ff. r
T.
0- Residential Swimming Pools OWNERS
WN ROSSSOR
Date Applicants FIRM NAME 40
CERTIFICATE OF EXEMPTION FROM W ERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by First 20 CITY Tel. No.
the permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this q pNCCgHN7K
permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensation Laws.
Additional
Total No. CITY Tel. No.
Date 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. i
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 11
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan —Other— CITY Tel. No. lc��
LICENSED CONTRACTORS DECLARATION LICENSE
Disp. — Room Air Condi — Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER ® � � � .
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. PR SED BY d
and Professions Code,and my license is in full force and effect.
'! /r 4e-.l
� Size&Type HP, KW, KVA, or KVAR t U U
License Numb �f �1 Hc. Class Up to 1 Incl. FINAL .
Over 1 to 10 Incl. DAT
E V DATION O
Contractor Date Over 10 to 50 Incl. FINAL U
E:1I am exempt u /der Sec. Over 50 to 100 Inc. BY LU
B.&P.C. for this reason Over 100 d
V10. Services; Swbd., MCC&Panelboards Z
e' 0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V ;2 01 5.5 A
❑ Exemption for Reg. MOver 1'000 Amp. or Over 600 V
int. Elect: # o .o o o'0 2
SINGLE FAMILY Tem Power Pole&Appurtenances
o 0
HOME OWNER-BUILDER DECLARATION p' , 7 3 82
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License o - 7a825
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code):
1' Misc. Conduits&Conductors 7�,1 .3.Le-
❑,I, as owner of the property, will do the work and the
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 �y
PERMIT ISSUING FEE U
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 3 ,
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
thea ve-mentioned rop ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
rp
ignatur f Ppittee Date ®'