HomeMy Public PortalAbout4821 ALESSANDRO AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 10181 APPLICATION FOR ELECTRICAL PERMIT
•1 her'ebe'affirm CE-806 that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certifico copy thereof (Sec. 3800, Lab. C.)
Policy No. Company S t l t e F li n d FOR APPLICANT TO FILL IN JOB
❑ �' rtified co is hereby furnished. EACH NO. FEE ADDRESS
� �e PY Y New Residential Bldgs. 8 Pools
® LOCALITYT e m l e city ,t C a .
Certified copy is filed with thfcnt buildin inspec- 1 & 2-Family, Sq. Ft $ — $ �tion department. Multi-familySq. Ft. 'NEAREST
CROSS ST.
idential Swimming PoolsDate 5/23 86 Applicant - OWNER OR
FIRMNAME Ru$$ Linfo d
CERTIFICATE OF EXEMPTIONM WORKER ' MAIL4 815 Alessandro
Outlets: Rec Light Sw._COMPENSATION INNCE 75, 3 2 . 2 5 ADDRESS
This section need not be completed if the work involved by
First 20
( p
the permit is for one hundred dollars ($100)or less.) Total No. Additional CITY T em l e C i t C del. No-2 85-419 6
I certifythat in the performance of the work for which this PLAN CHECK
P APPLICANT
permit 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
Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT R a mo r E l e c t r i c CoI n c
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 3.1 5 S . San Gabriel B 1
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY San Gabriel , C ael. No. 287-047
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
Disp. Room Air Cond. LICENSE
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER 4 21]9] Class. C-10
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSEA E
and Professions Code, and m license is in full force and effect. Power Apparatus& Large Appliances /�I/(` M
y Size &Type HP, KW, KVA, or KVAR' ( �
License Num r 4 179 Lic. ss CIG Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE /� VALID ION
Contractor at 86❑ Over 10 to 50 Incl. c/ I"
I am exempt unde Sec. Over 50 to 100 Inc. B BYLU
B-&P.C. for this reason Over 100
Date: Services, Swbd., MCC& Panelboards 1 5 0 15
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole & Appurtenances 9 4 6 9 9 A,
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 # o o o o,o 2
Law for the following reason (Section 7031.5, Business and
Professions Code): o.0 2 7 7 5
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)_ , '0*0 0 2 ],75'5
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 0523=86
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) 17 , 2E
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE1J7 . 7 Lender's Address2
I certify that I have read this application and state that the TOTAL FEE
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
here uth ize repres to 'ves of this Cou to enter upon
the ntioned r er for inspect' n purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig lure of Permittee Date