HomeMy Public PortalAbout4809 ALESSANDRO AVE_Electrical__ WORKERS COMPENSATION DECLARATION 400019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O
brei l 768663
t.,ffirm that I have a certificate of consent to self ce e06G
irtsure or a ertificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or a certified copy thereof(Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
❑Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ — $ LOCALITY jf-M Lf C/—. (f
hNEAREST on department Multi family Sq Ft CROSS ST "w f L(
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME uym� PATT;J t;
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets RecA<_LightSw y IL ADD
COMPENSATION INSURANCE 1 First 20 RESS
(This section need not be completed if the work involved by Total No �L Additional CITY Tel N � S
the permit is for one hundred dollars ($100)or less )
PLAN CHECK
I certify that in he performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner q
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ` ADDRESS \
Date Zv
d 0 k Additional Total No � CITY No
Applicant /may �� Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICATION
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
with comply with such provisions or this permit shall be Top — FAU —W H —
deemed revoked Hood — Fan —Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION Disp — Room Air Cond — LICENSE OR 1
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER Class
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROCESSED
and Professions Code and my license is in full force and effect
Size &Type HP KW KVA or KVAR O
License Number Lic Class Up to 1 Incl FINAL U
Over 1 to 10 Incl DATE �-� VALIDAT N �
Contractor Date Over 10 to 50 Incl FINAL F-
F]
❑ I am exempt under Sec Over 50 to 100 Inc BY U
Lu
B &P C for this reason Over 100
Services Swbd MCC& Ponelboards U)
Date 0 200 Amp Under 600 V Z
Signature 201 1000 Amp Under 600 V
❑ Exemption for Reg Maint Eject O\.er 1000 Amp or Over 600 V
§ 0551l A
SINGLE FAMILY
HOME OWNER BUILDER DECLARATION Temp Power Pole 8 Appurtenances # ° o o e 0 2
1 hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits
Professions Code) ( ° ° 2 2 5 0
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I as owner of the property will do the work and the Misc Conduits& Conductors e o 0 2 2 5 0�
structure is not intended or offered for sale(Section 7044 Other (See Complete Fee Schedule)—
Business and Professions Code) , 0829-88
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
Lender s Address C
I certify that I have read this application and state that the TOTAL FEED
above information is correct I agree to comply with all County 1
ordinances an tate laws regulating Electrical wiring and
hereby autho re esentatives of this County to enter upon
the above e perty forinspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
S at a of P mittee Date Os
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