HomeMy Public PortalAbout4929 ALESSANDRO AVE_Electrical__ WORKERS'COMPENSATION DECLARATION -886 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY c
copy thereof(Sec. 3800.Lab. C.)
Policy NO. Company FOR APPLICANT TO FILL IN JOB Q
❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS 1 . L �Q W
New Residential Bldgs.& Pools LOCALITY
❑ 1 & 2-Family, Sq.Ft. $ — $
Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft. CROSS STLo.
Residential Swimming Pools OWNER OR
Date Applicant ` FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:RecLight Sw. MAIL
COMPENSATION INSURANCE � O ADDRESS 1 C��/ /0(,lK.
(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 0 Tel.No.
•
S73 14-A
PLAN CHECK
I certify that in the performance of the work for which this permit 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 D ADDRESS
Total NO. 0;11 Additional CITY Tel.No.
0�e_ � ApplicaIC TO A PLICANT: I ak' hi rt'' f Fixed Appliances Not Over 1 HP PERMIT
Ran e— Heater_ D.W. APPLICANT
Exemption,you should become tett tot rs ensation g —
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 Class.
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBB ER
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PAOCE Y
Size& Type HP,KW, KVA,or KVAR � C
License Number Lic.Class Up to 1 Incl. FINAL, U
Contractor Date Over 1 to 10lncl. DAT90
�� �7� VALIDATION
❑ Over 10 to 50 Incl.
FINAL
I am exempt under Sec. Over 50 to 1.00 Inc. BY W
BAP.C.for this reason Over 100 N
Services,Swbd.,MCC& Panelboards Z_
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp. Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit T
a
I hereby affirm that I am exempt from the Contractor's License Law 4
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits I��•�•I
Code): 74B
17.613
61
❑ I,as owner of theproperty,will do the work and the structure Misc.Conduits& Conductors - EM
Other See Complete Fee Schedule) lLt?
is not intended or offered for sale (Section 7044, Business ( p
and Professions Code). ® TOT AL _7 ® 460
CONSTRUCTION LENDING AGENCY t:HECK 17.6[1
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHANGE ,013
Civ. C.).
L 1 1 PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE CIL—I00-1]001 '�10/26/9--i
Lender's Address Address J �0-Sek\ AJ lop i 228 'r} '1i�
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
representatives of this County to enter upon the above-mentioned
pro ty for inspecti purposes.
1k. 'D /2— O SEE REVERSE FOR EXPLANATORY LANGUAGE
SigTVature of Permittee Date