HomeMy Public PortalAbout5572 WELLAND AVE_Electrical__ 'CMRER3'CcOMP�EA;QflGi�4i DECLARA:,ON CE-806 10/81 APP CA710N '� p�j e ECTRIC/k L PC®MIT
I hergby affirm that I have nate of cYnsent to self CE-8066 Li-LL, W �!G] IIS L �e !ar/"k 6R 1
insure+0r a certific�tJe-� orkeAS'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
.!oi a•5ertified copy'thereof(SSec. 3800, Lab. C.)
Company 146hit -N— FOR APPLICANT TO FILL IN JOBI�
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS 1,Vc�.e-f1`/u
Certified copy is filed with the coup building Igspec- 1 &2-Family, Sq. Ft. _ $ —is LOCALITY ( C f
I' Vtrnen'92t. Multi-family Sq. Ft. — NEAREST nn
�i Residential Swimming Pools CROSS ST. D G��-he
Date Applicant vim' OWNER M `l
FIRM NAME C '6 c
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
Outlets: Rec Light Sw._
COMPENSATION INSURANCE ADDRESS
This section need not be completed if the work Involved b First 20
( p Y Total No.— Additional CITY S �!L(r Tei. No.
the permit is For one hundred dollars($100)or less.) '• ,
I certifythat'in the performance of the work for which this PLAN CHECK
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
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption, you should become subject to the Workers' Range_ Heater_D.W. APPLICANT A, 4)
Compensation provisions of the Labor Code, you must forth Oven _Dryer W.M.— ADDRESS �G
with. comply with such provisions or this permit shall be Top _ FAU —W.H. — 210 /
deemed revoked. CITY Tel. No. Z>
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ r A-11;",,e, 3 r Q
Disp. _ Room Air Cond. LICENSE OR /i Class. �'ii
"�
(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. U a
Size&Type HP, KW, KVA, or KVAR' c O
License Number-- Lic. Class C_11,10 Up to 1 Incl. FINAL V
ad
/�� Over 1 to 10 Incl. DATE, _� VA DATION
';'Contractor • Date Over 10 to 50 Incl.
FINAIV
❑ I am exempt under Sec. Over 50 to 100 Inc. Ru
B.&P.C. for this reason Over 100 U)
Services, Swbd., MCC&Panelboards
Date: 0 -200 Amp, Under 600 V •;P-71 9.7 A
Signature 201 - 1000 Amp. Under 600 V
Over 1000 Amp. or Over 600 V # 0 0 0, 0 0 2
1❑ Exemption for Reg. Maint. Elect. ( o - 70,94
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION o 70.945
Sign with One Branch Circuit
I�hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law fQQr the following reason (Section 7031.5; Business and O O 8 8 7
Professions Code):
\ Misc. Conduits&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)_
11 7044, Business and Professions Code).
l'•, CONSTRUCTION LENDING AGENCY I r
11 hereby affirm that there is a construction lending agency fort
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 I
' PERMIT ISSUING FEE
Lender's Address
4,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
th ab e-mentioned ty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Si' ature of•P,ermittee I bate