HomeMy Public PortalAbout4908 ALESSANDRO AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PER9IT
.I hereby affirm that I have a certificate of consent to self insure, CE-806G
'br a.c*tificate of Workers' Compensation,Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
co,,V_therevof (Sec. 3800,Lab. C.)
FbIICy NO. Company - FOR APPLICANT TO FILL IN JOB
ADDRESS-Og5�F
❑ Ce'tified*copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE
❑ 1 & 2-Family,Sq.Ft. $ _ $ .LOCALITY
Certified copy is filed with the county building inspection
department.' Multi-family Sq.Ft. NEAREST
CROSS S .
Date Applicant Residential Swimming Pools OWNER OFA
CERTIFICATE OF EXEMPTION FROM WORKERS' ARAM NAME (Jt7J/ 7/�
COMPENSATION INSURANCE Outlets:Req Light Sw. — ADDRESS Ifi9� /�C415,hvi�R-> ST
This section need not be completed if the work involved by the First 20
( P CITY �^/ ,�y/ Tel. No. g�
permit is for one hundred dollars ($100)or less.) Total No. Additional / "00.,0i� G/ 7 'ZJ
I certifythat in the. performance of the.work for which this permit PLAN CHECK
p P APPLICANT
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
Additional
Total No. J CITY •Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If,,after making this Certificate of Q
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. _ ADDRESS
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Class.
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT P SSED BY
`q �..
Size& Type HP,KW,KVA,or KVAR V
License Number Lic.Class Up to T Incl. FINAL
Over 1 to 10 Incl. DATE VALIDATION Q
Contractor Date Over 10 to 50 Incl FINAL U
❑ I am exempt under Sec. Over 50 to 100 Inc. BY �,/%� W
CL
B.&P.C. for this reason Over 100
N
Services,Swbd.,MCC & Panelboards
Date: 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
HOME OWNER-BUILDER DECLARATION
Sign with One Branch Circuit ACCT �
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
e3�'Sf 17.2.5
Code): °
EM
I„as owner of the property,will do the work and the structure Misc. Conduits& Conductors 1 X r ”
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) TOTAL
... .... .. .... !til 6 4�i. 7 r 25
and Professions Code). �. . .
CHECK 17.25
CONSTRUCTION LENDING AGENCY �p��/�^
GE
I hereby affirm that there is a construction lending agency for the CPII9I
.00
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ. C.).
PLAN CHECKING FEE COGO— 1 9/ 6/89
Lender's Name
PERMIT ISSUING FEE 55
17 q fm 31-1411,
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
d State la a in Electrical wiring, and hereby authorize
7ep entatvftsCountyto enter upon the above-mentioned
per for ins ction purp s.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa re of Pe ee Date