HomeMy Public PortalAbout4911 ALESSANDRO AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPUCATION FOR ELECTRICAL PERMIT {�
I hereby affirm that I have a certificate of consent to self insure, CE-806G LJ
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec. 3800,Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB e
ADDRESS
❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADD ��� isr,/9�✓
E! Certified co 1 & 2-Family,Sq.Ft. $ — $ LOCALITY
copy is filed with the county building inspection
department. Multi-family Sq. Ft. NEAREST
CROSS ST. GGIn/ J'i�
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—,Light — Sw. MAIL 1l /lL e� />_
COMPENSATION INSURANCE ADDRESS C 17 !'y9'�✓
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.N
I certifythat in the performance of the work for which this permit PLAN CHECK
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. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after, making this Certificate of APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
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 LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER Class.
Professions Code,and my license is in full force and effect. Power.Apparatus& Large Appliances DISTRICT NO. PROCESSED BY
Size& Type HP,KW,KVA,or KVAR d®
License Number Lic.Class Up to 1 Incl. FINAL U.
Over 1 to 10 Incl. DATE ' 2� VALIDATION x
Contractor Date Over 10 to 50 Incl. FINAL / V
Elam exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100
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
I hereby affirm that I am exempt from the Contractor's License Law TMa• •T r F
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits _
Code): _'f
Misc.Conduits& Conductors
I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) _
is not intended or offered for sale (Section 7044, Business , ;• �•:• � •=�•;;�
and Professions Code). ;U = e -`L=
33
CONSTRUCTION LENDING AGENCY h�� j
_•�,
I hereby affirm that there is a construction lending agency for the ,A.
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
PLAN CHECKING FEE !1;{j I�-i i�13_;{ ;•_3'
Lender's Name %-
PERMIT ISSUING FEE 5
I
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
and State laws regulating Electrical wiring, and hereby authorize
represe tives of this County to enter upon the above-mentioned
pro • y or ins ction p s. -
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature of Permittee Date