HomeMy Public PortalAbout4920 ALESSANDRO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
76A663
I hsreby affirm that I have�a certificate of cori'sent to self insure, �
or a certificate,of Worker's Compensation Insurance. or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy&reof(Sec. 3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB �!, ^
ADDRESS � Oo 1 C.
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
$ $, LOCALITY
❑ Certified co Is filed with the count building 1 &2-Family,Sq.Ft.
copy y g InSpeCtiCn _ NEAREST
department. Multi-family Sq. Ft. CROSS ST.
Residential Swimming Pools ASSESSOR ��
Date Applicant // MAP BOOK PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw.S OWNER OR
COMPENSATION INSURANCE FIRM First 20
(This section need not be completed if the work involved by theMAIL
permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS
I certify that in the performance of the work for which this permit CITY Tel.No.
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 PLAN CHECK r
1 p 9 APPLICANT
Total No. Additional �' ADDRESS
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY ,rte Tel.N /�
Exemption, you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked.
Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW, KVA,or KVAR ADDRESS
I hereby affirm that 1 am licensed under provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl. CITY _ Tel.N . /
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. }
Over 50 to 100 Ind. LICENSE OR Class.
REG.NUMBER f2
License Number Lic.Class
Over 100 DISTRICT NO. PROCESSED BY
Services,Swbd.,MCC&Panelboards � I cc
Contractor Date
0-399 Amp.Under 600 V FINAL O
DATE / H
❑ 400-1000 Amp. Under 600 V /6
I am exempt under Sec. Over 1000 Amp.or Over 600 VFINAL ! r VALIDATION W
B.&P.C.for this reason BRANCH CIRCUIT FEES BY CL
Date: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg. Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances 2�!TF
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCT.0
a8a
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 Vin�(_
�
Code):❑ t TT Misc.Conduits&Conductors 1 ITEMS
EMS
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 93 - 311
and Professions Code). CHECK 83.30
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for the CHANGE =
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE 0000-0001 4,/ 9/96
Lender's Name
PERMIT ISSUING FEE (� 5/8 1 Ah{10a g
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above information is correct. 1 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
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for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
TIRE OF P MITT DATE