HomeMy Public PortalAbout4814 ALESSANDRO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(t2-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, a,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY-DIV.
copy thereof(Sec. 3800 Lab.,C.)
Policy NO. Company FOR APPLICANT TO FILL IN JOB l l
❑
ADDRESS I. y
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
1 &2-Family,Sq. Ft $ $ �� X1 �,"
❑ . — 5
Certified copy is filed with the county building inspection _ NEAREST
department. Multi-family Sq. Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
SS SSOIRc /y� yyy /fly f wg
L v PAGE071 '! PARCEL 0 ✓
CERTIFICATE OF EXEMPTION FROM WORKERS' 12i OWNER OR
COMPENSATION INSURANCE Outlets:Rea L Light_a r SW. �7D FIRM NAOR �i� �t � it
First 20 �� `� MAIL /y
(This section need not be completed if the work involved by the ADDRESS V
c�'� J
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY eA.0 P�� Tel
is issued, I shall not employ any person in any manner so as to
PLAN CHECK
become subject to the Workers' Compensation Laws. LightingFixtures First 20. f y APPLICANT
Total No. 7�C/ �O AF Additional
- ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HR
NOTICE TO APPLICANT; If, after making th,is Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with Such PERMIT
provisions or this permit shall be deemed revoked. PowerApparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code, and my license is in full force and effect. Over 10 to 50-Incl.
SE OR
Over 50 to 100 Incl. REG.NNUM ER Class. d
Over 100 DISTRICT NO. PRO SSED BY O
License Number Lic.Class U
Services,Swbd.,MCC&Panelboards V ��rlLA����it,/ fr
0-399 Amp.Under 600,V FINAL O
Contractor Date DATE F-
400-1000 Amp.Under 600 V 2❑ VALIDATION U 1 am exempt under Sec. W
Over 1000 Amp.or Over 600 V FINAL a
B.&P.C.for this reason BY
BRANCH CIRCUIT FEES
Date: 15A,or 20A, 120V,Lighting or Recept. Z
=ok— 1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATIONf
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law ,.•. .,--
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
1, as owner of the property,will do the work and the structure Misc.Conduits&Conductors
s 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 NHN'Un
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE ±r ssf-5—)03�S_r
Lender's Name
PERMIT ISSUING FEE 7/ E
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lei
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the 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 the above-mentioned property
for inspection purpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE
SI OF PER EE 1 DATE -