HomeMy Public PortalAbout5019 ALESSANDRO AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION
wTION FOR ELECTRICAL
p ECTRIC/�p PERMIT JJ��
�I hereby affirm that I have a certificate nf,cpnsent to self insure, CE-806G L H '�J fl L t+ fl f11� r f1,V1
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.38QO,La). C.)
Policy No. Company 4 FOR APPLICANT TO FILL IN JOB
❑ Certified copy is reby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs.& Pools .
Certified copy is filed with the county building inspection
1 & 2-Family, Sq. Ft. $ _ $ LOCALITY
department. Multi-family Sq. Ft. NEAREST
CROSS ST.
Date — Applicant Residential Swimming Pools OWNER R n
CERTIFICATE OF EXEMPTION FROM WORKERS' y FIRM 1&�� .
COMPENSATION INSURANCE Outlets:Re, Light t 2 �/0 �4Z Q AAI RESS O�c/��
(This section need not be completed if the work involved by the First 20 /P
permit is for one hundred dollars($100) or less.) Total No. Additional IAN I.No.
I certify that in the performance of the work for which this permit PLAN CHECK
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
Total No.d— Additional
Kof CITY Tel.No.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP pia y
Exemption,you should become subject to the Workers'Compensation Range— Heater_ D.W. _ APFtif N
14
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS o
provisions or this permit shall be deemed revoked. Top — FAU _ W.H.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY � Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. — Room Air Cond. REG.NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. O PROCESSED BY
Size & Type HP,KW,KVA,or KVAR j'o 0
License Number :/ ` Lic.Class Up to 1 Incl. FINAL / U
Over 1 to 10 Incl. DATE /� � '�� VALIDATION W
Contractor4 Date 11 t1 Over 10 to 50 Incl. U
❑ FINAL A
I am exempt under Sec. Over 50 to 100 Inc. BY / ��� W
B.&P.C. for this reason Over 100 Cv� 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
f
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 -�
Code): 3 aifR
El 1,
I,as owner of the property,will do the work and the structure Misc.Conduits & Conductors si
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) _ ® TOTAL 3 :1 = 00
and Professions Code).
CONSTRUCTION LENDING AGENCY CHECr 1.0 0
I 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 i- •t1c•.If0f
Lender's Name 0000-00010000-0001t�.i, ;0
PERMIT ISSUING FEE 3305 1 AM 8:41
Lender's Address _
I certify that I have read this application and state that the above TOTAL FEE 31
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&f ' s �turposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
�,o 6 o
ignature of Permittee Date V