HomeMy Public PortalAbout5566 WELLAND AVE_Electrical__ WORKERS' I have
certificate
DECLARATION 76-663 10/01 APPLICATION FOR 91LECTRICAL PERMIT '13��7
I hereby affirm that I have a certificate of consent to self CE-BO6G APPLICATION
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified
j copy thereof�$ec. 3800 Lob. WI(4
Policy No. r"W'VG` 2t'o_//''p�ny �v FOR APPLICANT TO FILL IN JOB (�1 G
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS W
❑ Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft.--Mf $ — $. LOCALITY
tion de artment. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST. Q,c
Date pp I q/ _ ,1 rA
G A licant FIRM NAME C CZ5
CERTIFICATE OF EXEMPTION FROM WORKERS' ` MAIL
COMPENSATION INSURANCE Outlets: Rec Light Sw._ ADDRESS-)
(This section need not be completed If the work involved by First 20
the.permit is for one hundred dollars(.$100)or less.) Total No. Additional CITY R-C-( Tel. No.
I certify that in the performance of the work for which this APPLICANTK
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'
NOTICE 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 Labpr Code, you must forth- Oven —Dryer —W.M.— ADDRESS4,1,o ZZi: V I v
with comply with such provisions or this permit shall be Top — FAU —W.H. — CITY Tel. IVo.�p9_J?6
deemed revoked. Fan Other— eADA
_
LICENSED CONTRACTORS DECLARATION Hood _ LICENS OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond: REG. NUMBER r Class. 6(p
(commencing with Section 7000) of Division 3 of the Business , DISTRICT NO. PROCESWD BY
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances V1
g-?7rT ' G—Id.
Size 8 Type HP, KW, KVA, or KVAR'
License Number Lic. C ss Up to 1 Incl. FINAL^� / _� V
VL C' Over 1 to 10 Incl. DATE`/ / VA -TION
Contractor� rL & ate 4 Over 10 to 50 Incl. u
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100 �,�• U)
Date: Services, Swbd., MCC&Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V 7 1 9.5 A
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY #1- 002
Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit `1 0 0 7 Q 9 4
I hereby affirm thdt I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and - 70,945
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors 0608-87
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 j
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
a ve-mentioned prop for insp�cti n p rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SYgnature of Permittee -/�/ Oa Date i