HomeMy Public PortalAbout4815 ALESSANDRO AVE_Electrical__ 1 "
r WORKERS COMPENSATION DECLARATION 63 10i81 APPLICATION FOR ELECTRICAL PERMIT
I herebyCE 8�r-affirm that I have a certificate of consent to self CE 806G , `
ivisure ora certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) I a
Policy No Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS �S SSO to "
❑ Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ — $ LOCALITY �o
tion department , Multi family Sq Ft — NEAREST
Residential Swimming Pools CROSS ST ee
Date Applicant - OWNER OR t
CERTIFICATE OF EXEMPTION FROM WORKERS FIRM NAMEL-L w
COMPENSATION INSURANCE OuTlets f�ec Light
t � Sw SIL
ADDRESS YflSr 550w%A.d f"0
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This section need not be completed if the work involved b First 20
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the permit is for one hundred dollars (6100)or less ) Total No Additional CITY Tel No g5—q/
I certify that in the performance of the work for which this PLAN CHECK
i APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation ws Lighting Fixtures First 20 ADDRESS
Additional
Total No
Date �'TO Applicant / CITY T I o
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If aft a k i n g this C rtifi ate Lf APPLICANT
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 I CITY Tel No
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
Disp _ Room Air Cond LICENSE Class
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO 4 C i/ PROCE ED BY >_and Professions Code and my license is in full force and effect J*�— U}V(
Size &Type HP KW KVA or KVAR d
License Number Lic Class Up to 1 Incl FINAL _ V
Over 1 to 10 Incl DATE �d 4 A Ac
Contractor Dare +Over 10 to 50 Incl FINAL / V o
F-10 oI�o 'Z V
I am exempt under Sec Over 50 to 100 Inc BY 9 o e 1yys
B&P C for this reason Over 100 e e ° 1 O O
Date Services Swbd MCC& Panelboards o 8.2 0 t Z
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V
❑
Exemption for Reg Ma — Over 1000 Amp or Over 600 V
mt Elect ``
SINGLE FAMILY � 9'
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 Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and
Prof ions Code)
I as owner of the property will do the work and the Misc Conduits &Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)-
7044(Business
chedule)_7044(Business 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 PERMIT FEE - (Sub Total)
(Sec 3097 Civ C ) _
f
PLAN CHECKING FEE
Lender s Name
,PERMIT ISSUING FEE }
Lender s Address n
I certify that I have read this application and state that the TOTAL FEE T if✓
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring and '
hereby authorize representatives of this County to enter upon r
the ob vk.fPelftee
ioned pr erty fo inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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