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Home My Public Portal About5562 WELLAND AVE_Electrical__ I � WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATIONFOR ELECTRICAL PERMIT !'moi h'ylr&'t�r affirm that I have a certificate of consent to self CE•e06G insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES i BUILDING AND SAFETY or a certified copy thereof (Sec. 3800, Lab. C.) Policy No7tj ib Y2 compo Rik 12 i FOR APPLICANT TO FILL IN JOB Z Certified copy is hereby furnished. .New Residential Bldgs. &Pools, EACH NO. FEE` ADDRESS ❑ $ — g• LOCALITY Certified copy is filed with the county building inspec- ! 1 &2-Family, Sq. Ft. NEAREST tion department. r Multi-family Sq. Ft. — �� pp j fff � d�( � Residential Swimming Pools OWNER OR Dat —Applicant {fir, ✓/ FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE ADDRESS &i (This section need not be completed if the work involved by First 20 I r Tel. No. i ,s. C ^Z the permit is for one hundred dollars($100)or less.) Total No. AdditionalCITY 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 i so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First.20 ADDRESS Additional i Total No. CITY Tel. No. Date Applicant A4 Fixed Appliances Not Over 1 HP PER NOTIC TO APPLICANT: If, after making this Certificate of ! APPLICANT ° 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. ADDRESS with comply with such provisions or this permit shall be Top _ FAU —W.H. — deemed revoked. Hood _ Fan _Other_ CITY S ° Tel. No. ,L LICENSED CONTRACTORS DECLARATION LIq;ENSE R 1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG.NUMBER Class. (commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCESS p� and Professions Code,and my license is in fulltforce and effect. Power Apparatus&Large Appliances �:—� `� O Size&Type HP, KW, KVA, or KVAR License Number Lic. Class F NAL , Up to 1 Incl. y L G'OA,31+6 Over 1 to 10 Incl. TE O Contractor rel �/tC n ate I VALIDATION ❑ ° x`—^+—t Over 10 to 50 Incl. FINAL 'Y W I am exempt under Sec. Over 50 to 100 Inc. 8 p.' Over 100 fn B.&P.C. for this reason Date: Services,Swbd., MCC 8 Panelboards 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V " ;16 5 7.5 A Exemption for Reg. Maint. Elect. # 0,00 - 2 SINGLE FAMILYIS HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances I 1 - 2550 Sign with One Branch Circuit 0 0 0 2 5 5.0' 1 hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and Q 2 2 5-8 7 Professions Cade): 0 1, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ 7044, 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) i (Sec. 3097, Civ. C.). PLAN CHECKING FEE ''II Lender's Name PERMIT ISSUING FEE / V Lender's Address C I certify that I have read this application and state that the i TOTAL FEEv C 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 property for inspection purposes. j SEE REVERSE FOR EXPLANATORY LANGUAGE �• 22 I Signature of Permittee to WORKERS'COMPENSATION DECLARATION 76A663 10181 w`� ��TIOR! FOR EL�C�TRICAL PERMIT y 31-WIP I hereby affirm that I have a certificate of.consent to self CE-8066 insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof JSec. 3800, Lab. C. Policy No. 10ECCE Company G Vlsb(rf enc FOR APPLICANT TO FILL IN JOB ` 1� ,{�r ® Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS D /`i d _ ❑ Certified copy is'filed with the co ty building ins ec- 1 &2-Famil S Ft.. f S'I $ = $ LOCALITY ��• Y� 9• tion de rtment. Multi-family S Ft. WM NEAREST p ( � y 9' CROSS SL Residential Swimming Pools OWNER OR CTT,�I Date Applicant FIRM NAME 5��v ' 'v FTE OF EXEMPTION FROM WORKERS' Outlets: Rec Li ht Sw._CERTIMAIL COMPENSATION INSURANCE ADDRESS3II �. � g1� ' b First 20 (This section need not be completed If the work Involved by Total No. Additional CITY �� `FL C Tel. Nof�� the permit Is for one hundred dollars($100)or less.) PLAN CHECK 1 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 20 .ADDRESS Total No. Additional CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT Q NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT LIQG �� actl'► fie A,JL t I A Exemptiori, you should become subject to the Workers' Range_ Heater_D.W. Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M.— ADDRESS _ with comply with such provisions or this permit shall be Top _ FAU —W.H. — CITY �( Tel. No. p deemed revoked. yet a'j/L. I'` 3 � �U Hood _ Fan —Other_ LICENSED CONTRACTORS DECLARATION LICENSE OR ^7 I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG.NUMBER 47 /rr�S Class.C— (commencing with Section 7000)of Division 3 of the Business DISTRICT PROCF�SSED BY and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances Size&Type HP, KW, KVA, or KVAR' License Number Lic. Cl ss10 Up to 1 Incl. FINAL �Offto'c� V'j11L Over 1 to 10 Incl. DATE ALIDATION Contractor Date 8 Over 10 to 50 Incl. FINAL U ❑ I am exempt under Sec. Over 50 to 100 Inc. BY Ul B.&P.C. for this reason Over 100 Date: Services, Swbd., MCC&Ponelboards > -;971 9.3A 0 -200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V # o 0 0 0 0 `Z ❑ Over 1000 Amp. or Over 600 V I o.o 7(1 9 4 Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole&Appurtenances - 70,9405 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ' 06,08-87 1 hereby affirm that I am exempt from.the Contractor's License Additional Sign Branch Circuits Law for the following reason (Section 7031.5, Business and Professions Code): ❑ Misc. Conduits 8 Conductors I, as owner of the property, will do the work and the structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ 7044, 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 Lender's Address 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 /Ike ab ve-mentioned pro erty for inspecti�u,pQoses. SEE REVERSE FOR EXPLANATORY LANGUAGE gnature of Permittee Date