HomeMy Public PortalAbout5570 WELLAND AVE_Electrical__ WORKERS' I have
certificate
DECLARATION CE-806 10/81 APPLICATION TION F ECTRICAL PERMIT
%Z1 t'JY147 del
I hereby affirm that I have a certificate of consent to self CE-8066. ® ® �a/`O
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy fherr?eo�f,(Sgc. 3800, Lab. C.) 17 A
Policy No. zo7ca Company FOR APPLICANT TO FILL IN • JOB 4
EACH NO. FEE ADDRESS ID
Certified copy is hereby furnished. New Residential Bldgs. &Po0Jsj�
❑ Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. fb /� $ — $ LOCALITY 1 Ci
tion de artment. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools ', , OWNER CROSS ST R ���//•rrS�� .l
Date Applicant • '-FIRM NAME
CERTIFICATE OF EXEMPTION ROM WORKERS' , MAIL
COMPENSATION INSURANCE Outlets: Rec Light Sw._ > > ADDRESS ( !D
s sen neenote completed If the work Involved First 20
(Thisection d bom p 9 Total No. Additional CITY I c�£(� 7e1. No.
the permit is for one hundred dollars($100)or less.)
ECK
I certifythat in the performance of the work for which this PLAN CH
e p 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 rr
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT ld C_
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 AJ4vLV_y
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood Fan _Other— CITY N �
Tel.
— No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class.C—It;,
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCES D BY
and Professions Code,and m license is in full force and effect. Power Apparatus&Large Appliances C6
my
&Type HP, KW, KVA, or KVAR .,]
License NumberS+77-f2a__ Lic. Class C� Up to 1 Incl. FINAL
2 [ Over 1 to 10-Incl. V IDATION
Contractor J Date Over 10 to 50 In . G ` O
4U
F1I am'exempt under Sec. Over 50 to 100 Inc. FI L 271 98A LU
BAP.C. for this reason Over 100 H
Services, Swbd.,.MCC&Panelboards # 0 0 0 0.0 2
Date: 0 -200 Amp. Under 600 V I o o 7 a 9 4
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Mainf. Elect. Over 1000 Amp. or Over 600 V o o,o 7 0.9 4 60
SINGLE FAMILY Temp. Power Pole&Appurtenances 060887
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 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
Lender's Name PERMIT ISSUING FEE U
Lender's Address
I certify that I have read this application,and state that the TOTAL FEE i
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
t abo e-mentioned property for inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Slinature of Permittee D to