HomeMy Public PortalAbout4844 ALESSANDRO AVE_Electrical__ L r��i COMPENSATION DECLARATION 63 10/81 APPLICATION FOR ELECTRICAL PERMIT
�._ta�erebyfirm irm that I have a certificate of consent to self CE CE806G
nsuP or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES i BUILDING AND SAFETY
or a c& fled copy thereof (Sec 3800 Lab C )
w�
Policy No Company FOR APPLICANT TO FILL IN JOB L c
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS a Q
Certified copy is filed with the county building +nspec 1 & 2 Family Sq Ft $ _ $ LOCALITY
tion department Multi family Sq NEAREST Ft O z
Residential Swimming Pools CROSS ST OWNER OR
Date Applicant
'' 77 `] FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec�Light Sw L MAIL
COMPENSATION INSURANCE First 20
15 ADDRESS
iti
(This section need not be completed if the work involved by Additional 1e
CITY No
the permit is for one hundred dollars ($100)or less ) Total No Add
that in the performance of the work for which this PLAN CHECK
I certify p APPLICANT
permit is issued I shall not eAmak-Ing
n in any manner
so as to become subject to tpensatio La s Lighting Fixtures First 20 ADDRESS
Additional
Total No CITY Tel No
Dat Applic Fixed Appliances Not Over 1 HP PERMIT /
NOTICE TO APPLICANT Ifis Cert scat of APPLICANTe2 Z f l
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 — ADDRESSCwith comply with such provisions or this permit shall be Top _ FAU —W H —
deemed revoked Hood _ Fan _ Other_ CITY O Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp — Room Air Cond REG NUMBER Z Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCESS Y
and Professions Code and my license is in full force and effect Power Apparatus & Large Appliances ( !l/� _ �
y !� Size &Type HP KW KVA or KVAR UXU O
License Number` (,{��2 l Lic Class r �/ Up to 1 Incl FIAz
NAL V
/ Over 1 to 10 Incl DATE — / VALID ON
Contractor ate FI
Over 10 to 50 Incl t—
NA
I am exempt under Sec Over 50 to 100 Inc BY / W
CL
B &P C for this reason 1 Over 100 of
Services Swbd MCC& Ponelboards
Date 0 200 Amp Under 600 V
Signature ` 201 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V - -980 4 A
Exemption for Reg Maint Eject
*to a oio 2
SINGLE FAMILY Temp Power Pole & Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit ( o - 2900
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 , o - 29005
Professions 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)_ , 0.02 -87
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 ) '
PLAN CHECKING FEES _
Lender s Name t
PERMIT ISSUING FEE
Lender s Address
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 u raze representatives of this County to enter upon
t above m o ed pr.pero for insp ction purpos s
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Per ittee Da tre