HomeMy Public PortalAbout5627 WELLAND AVE_Electrical__ WORKERS'COMPENSATION DECLARATION jI26�68 DPW 3/87 I
hereby affirm thdit I•have`c certificate of consent to self i.7~ APPLICATION FOR ELECTRICAL' PERMIT Q
CUM
insur!'nom certificate of Workers'Cor>A�erisation Insurance, i COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or orrtifie�d copy thereof(Sec. 3800, Lab. C.) j
I Policy No.. Company FOR APPLICANT TO FILL IN' JOB'
❑Certified co is hereby furnished: EACH NO. FEE ADDRESS ��lJ ./
� PY• Y : New Residential Bldgs. 8 Pools �
❑Certified co is filed with the count building inspec- 1 &2-Family, S Ft. $ — $ LOCALITY�-
PY Y 9 P Y. q NEAREST
tion department. Multi-family Sq. Ft. I CROSS ST.
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME e
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
I' Outlets: Rec Light Sw._
I COMPENSATION INSURANCE Firsf 20 ADDRESS
(This section need not be completed if the work Involved by Total No. Additional I CITY Tel. No.
the permit is for one hundred dollars($100)or less.) ti t ; PLAN CHECK
I certify that in the'performance of the work for which this I APPLICANT
permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to:become subject to.the Work s'Compensate n La s.
_ Additional
Total No. CITY Tel. No.
Date Applicant � � �C' Fixed Appliances Not Over 1 HP PERMIT `—
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION •Q, L_e ti
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 D i
with comply with such provisions or this perrriit.sholl be Top — FAU —W.H. —
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deemed revoked. Hood — Fan —Other— CITY Tel. No
LICENSED CONTRACTORS DECLARATION ' LICENSE OR
Disp. _ Room Air Clas .�Cond. — �rG j
I hereby affirm that I'am licensed under provisions bf Chapter 9 REG. NUMBER` I —/L3
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRI T O. P ED
and Professions Code,and:my.license is in.full force and effect. , D
I+ Size&Type HP, KW, KVA,or KVAR 0
License Number Lic. Class y Up to 1 Incl. FINAL V
Over 1 to 10.Incl. j DATE VALIDATION
Contractor Date 0
❑ Over 10 to 50 Incl.
FINAL
I'am exempt under U
Sec. Over 50 to 100 Inc. I gY / LU
B.&P.C. for this reason Over 100 p-
IV
D�: ' °, Services; Swbd., MCC&Panelboords , r / Z
IV
0-200 Amp. Under 600 V
'Signature 201 - 1000 Amp. Under 600 V
F-1 Exemption 1000 Amp. or Over 600'V
Exemption for Reg. Maint.•Elect. _
SINGLE FAMILY I 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 Ii ACCO'e s
Law for the following reason (Section 7031.5; Business and ! Additional Sign,Branch Circuits S
Professions Code): f _3307 48 1130
Misc. Conduits&Conductors I' ITEMS
❑ I, as owner of the property, will do the work and-the ki Complete Fee Schedule Com lSee Other Oth _
structure is not intended or offered for sale(Section 7044, ( P ) ® TOTAL a��
Business and Professions Code): CASH 48.00CONSTRUCTION LENDING AGENCY
I hereby affirm that there is.a constructidn lending agency for e
the,performance of the work for which this permit is issued PERMIT FEE C � '
p p (Sub-Total)
(Sec. 3097,Civ. C.),
PLAN CHECKING FEE
Lender's Name 0000-0001 1/25/90
Lenders Address PERMIT ISSUING FEE 3482 1 AM11:12
1 certify that I have read this application and state that the TOTAL FEE
above information is correct. 1 agree to comply with all County
-ordinances.and State laws regulating Electrical wiring, and ;
hereby authorize rept ntatives of this County to enter upon
the above-mentio perty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
®s.
Signature Ittee Date
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