HomeMy Public PortalAbout5564 WELLAND AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81 �pI��B�A°o°I® FOR Ed � RICAL PERMIT
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,(Sec. 3800, Lab. C.) In
W MPolicy No! 2ComDany FOR APPLICANT TO FILL IN JOB 1►Ir-1 r Jl.,tl YsiA
CSDW—
ertified co is hereby furnished. EACH NO. FEE ADDRESS UU�L�r'NI' TTV
PY Y New Residential Bldgs. P o�s
❑ 1 &2-Family S FtFt.. ( $ _ $ LOCALITY e G�
Certified copy is filed with t e county buil/dinging ' cc- y' q' 'NEAREST
tion department. �l/ Multi-family wi m CROSS 57.
-Residential Swimming Po s ��'•• OWNER OR'
Date Applicant \ F cc) y ��c,
FIRM NAMEA�.0 C� 1.
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Li ht Sw MAIL
COMPENSATION INSURANCE g ADDRESS 1311 ti. UALWE. Wkff If v
(This section need not be completed if the work Involved by Total No. First CITY AjiCq_ L'pt Tel. No.
the permit is for one hundred dollars($100)or less.) Additional 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 20 ADDRESS
Total No. Additional CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT II
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT R!5",
i �� f d,
Exemption, you should become subject to the Workers' Range— Heater_D.W. .�
Compensation provisions of the Labor Code, you must forth- i Oven — Dryer _W.M.— ADDRESS ),v It–
with .comply with such provisions or this permit shall be Top FAU —W.H. — CITY / , Tel. No. j0�� 3�
Hood Fan —Other—
deemed revoked. / 1 . M
_
LICENSED CONTRACTORS DECLARATION LICENSE OR //��"�
I hereby affirm that I qm licensed under provisions.of Chapter 9 Disp. Room Air Cond. REG.NUMBER K77.1-S-5' Class. e/�
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO. ^ �`/ PROC BY
and Professions Code,and my license is in full force and effect. `4/, aV( IL
Size&Type HP, KW, KVA, or KVAR' L
License Number 4:�M ic. Cass 6–I'D FINAL {.8
Up to 1 Incl.
S_,S Over 1 to 10lncl. DATE 09
VA D TION
Contractor G'�'� >S Date Over 10 to 50 Incl. t–.
FINAL U
❑ I am exempt under Sec. Over 50 to 100 Inc. BY 71 9.4 A
Over 100
B.&P.C. for this reason
Services, Swbd., MCC&Panelboards # 0'a 0 0 0 2
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V o o ']Q O[�
❑ Over 1000 Amp. or Over 600 V .0 0'0 7 Q 9 4 C
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp..Power Pole&Appurtenances 0 0 8-8 7
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I 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):
❑ i, as owner of the property, will do.the work and the I 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)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lerider's Name
PERMIT ISSUING FEE
Lender's Address TOTAL FEE
I certify.that I have read this application and state that the s�
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
5c=
inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Permittee D te�