HomeMy Public PortalAbout4905 ALESSANDRO AVE_Electrical__ WORKERS COMPENSATION DECLARATION CE 806G (2 8b) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
FOR APPLICANT TO FILL IN JOB q /
Policy No Company PACNO FEE ADDRESS
New Residential Bldgs &Pools
Certified copy is hereby furnished 1 &2 Family Scl Ft — $ LOCALITY
OMulti family Scl Ft NEAREST
Certified copy is filed with the county building inspection CROSS ST ,fQ(,eJCi2 Zuyf/
department Residential Swimming Pools OWNER OR
1 �� FIRM NAME
Date Applicant Outlets Rec1 Light Sw ,[� Q MAIL /7j
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS ) Total No s2/ Additional 12 Q CITY Tel No 6
COMPENSATION INSURANCE
PLAN CHECK I d
(This section need not be completed if the work involved I Lighting Fixtures First 20 O Q O APPLICANT O
by the permit is for one hundred dollars ($100) or less) /� ADDRESS
Total No M/� Additional 0
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No
I, is issued I shall not employ any person in any manner i PERMIT r W
so as to become subject to the Workers Compensation Laws Range_ Heater_D W ; APPLICANT a
Oven Dryer W M ADDRESS Z
Date���pplicant � � � Top FAU �WH �
Hood Fan _Other_ 11^ CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ 7 Q LIC OR p�
Exemption you should become subject to the Workers REG NUMBER p Class a`0
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCESSED BY
comply with such provisions or this permit shall be
dee
deemed revoked Size&Type HP KW KVA or KVAR a
Up to 1 Incl
� FINAL
Over 1 to 10 Incl
LICENSED CONTRACTORS DECLARATION I DATE ��� VALIDATION
Over 10 to 50 Incl ki
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
9 (commencing with Section 7000) of Division 3 of the Busi Over 100 BY I A '
ness and Professions Code and my license is in full force and z"b
effect Services no >`
License Number Lic Class 0 200 Amp Under 600 V
201 1000 Amp Under 600 V _
Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit '
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code) _I2432 1 A
Misc Conduits&Conductors
I as owner of the property will do the work and the Other (See Complete Fee Schedule)— # 0 0 0 o o 2
structure is not intended or offered for sale (Section _
7044 Business and Professions Code) 2 0 0 4 7 10
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency o 0 0 [( ] v
for the performance of the work for which this permit is PERMIT FEE (Sub Total) fQ
issued (Sec 3097 Civ C) jig `3 09-8
Lender s Name PLAN CHECKING FEE (One Fourth Permit Feel
Lender s Address PERMIT ISSUING FEE 1),1,4
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
hereby authorize representatives of this County to enter upon
the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sign-atueto-f Permittee Date
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