HomeMy Public PortalAbout5620 WELLAND AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE-806G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec. 3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB -
❑ ADDRESS
Certified copy is hereby furnished. EACH NO. FEE
New Residential Bldgs.& Pools
.� S —� Certified copy is filed with the county building inspection 1 & 2-Family, q•Ft. $ $ LOCALITY
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_t Light Sw. MAIL
COMPENSATION INSURANCE ADDRESS
This section need not be completed if the work involved b the First 20
( p y Total No. Additional CITY Tel.No.
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
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
Additional
Total No. •� CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS ,f;
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR
REG.NUMBER Class. }^:
(commencing with Section 7000) of Division 3 of the Business and 0-1
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY 0
Size& Type HP,KW,KVA,or KVAR W
License Number Lic.Class Up to 1 Incl. FINAL --I
Over 1 to 10 Incl. DATE VALIDATION N.
Contractor Date Over 10 to 50 Incl.
❑ FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY �
B.&P.C.for this reason Over 100 0
Services,Swbd.,MCC& Panelboards , a
Date: 0-200 Amp,Under 600 V
W
Signature 201 - 1000 Amp.Under 600 V IJ
❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits
for the following reason (Section 7031.5,Business and Professions
Co ):
Misc.Conduits& Conductors
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ,
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(Sec.3097, PERMIT FEE (Sub-Total)
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 above TOTAL FEE
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. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date
76A�`"63=C1806 8-62
w ;� APPLICATION FOR ELECTRI AL PERMIF `1
F
COUNTY OF LOS ANGELES
DEPARTMENT OF COUNTY ENGINEER BUDDRESS.ILDING Q
BUILDING AND SAFETY DIVISION A
JOHN A. LAMBIE, COUNTY ENGINEER -
WILLIAM A.JENSEN,S.UP'T OF BUILDING LOCALITY
NEAREST
FOR APPLICANT TO FILL IN CR ST.
RECEPT. TOTAL NO. EACH FEE
OUTLET= FIRST 20 2 S;2o $
Br
Q OWNER
L16NT
H MAIL
swlTCa, / ADD'L ®•ADDRESS
OVER 20 170
bo
LIGHTING Flasr 20 /iJ .20 Q® CITY A� TEL.NO.
FIXTURES]:L�AL
OV OR ZO (p •10 3& ELECTRICIAN VV A
RANGES CLO.DRYERS WTR.HTRS. 1:00 ADDRESS ifti
GARB.DISP.4SO BTA.COOKp
CITY 17� AJ TEL.NO. ��C9
DISHWABN. AUTO.-WASH. .10 STATE
SPACE HTIIS. BTA.APP.(Va H.P.MAX.)' 60 .SO I..ICENSE NO. ,�
MOTORS: OVER NOT OVER H.P. DISTRICT N G OU.P. NE PR E
0 1 1.00 ,
1 s 1.50 INSPECTION RECORD
s a 2.00 S /X YDS
a_ 1s 2.150 ,
1S 150. 5.00 --
s0 100 5.00
SIGNS: NO..TRANS. p[
NO.LAMP8 OOi
SERVICE 0.600V-NOT OVER 200A1.00
SERVICE O-SOOV-OVER 200 A. 2.00 y
SERVICE OVER 600V 5.00 a
MISC. \
PERMIT ISSUING FEE 12.00 40
SUPPLEMENTAgY PERMIT ISSUING FEE 1.00 '
TOTAL FEE
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION - APPRO %DATE/'/ ��/ INSPECTOR'S 836HATURE
AND STATE THAT THE ABOVE IB CORRECT AND AGREE TO COMPLY CONDUIT AJJC�k VY-"(. - ''�✓✓'�U
WITH ALL.•COUNTY ORDINANCES AND STATE LAWS REGULATING
ELECTRICAL WIRING. WIRING %
I HEREBY CERTIFY THAT 1 AM PROPERLY REGISTERED AND/OR r
LICENSED-AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF 'FIXTURES 1 rY
CALIFORNIA OR THAT 1 AM THE LEG OWNER OF,THE ABOVE
DESCRIBED RESIDENTIAL PROPS .POWER !, / �(f /Ig{„! -('� •\
SIGNATURE / UTILITY CO. IFIE / lAY i c K f,llf a:
OF PERMITTE °” `" t •• \_I;I
FINAL. � . 1 V '
LIDATION A,ItrHUR C. VEIT
CK MO CASH r SUPERVISING ELECTRICAL ENGINEER
L1110 3 1 7 3 0 DC 5 2 D 268.60~