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HomeMy Public PortalAbout5031 ALESSANDRO AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT I hereby-affirm that I have a certificate of consent to self CE-806G 'insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) e Policy No. ) f "� Company: I��=IJ�I�rilr� FOR APPLICANT TO FILL IN JOB / ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS Le NbA&,, $ _ $ LOCALITY j y�-- I�Certified copy is filed with the ounty building inspec- 1 &2-Family, Sq. Ft. — >� r!. LAJ tion partment. _ Multi-family Sq. Ft. NEAREST / CROSS ST. l C o-� Residential Swimming Pools OWNER OR M / Date Applicant FIRM NAME m 1 CAA1Q.. - 0Al CERTIFICATE OF EXEMPTION FR WORS' � MAIL COMPENSATION INSURANCE First Outlets: Rec Light Sw._ Q ADDRESS (This section need not be completed if the work involved by Total No.� Additional / CITY' e1 Cl T Tel. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit 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 � Date Applicant Total No.� CITY Tel. No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. APPLICATION Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS S L IU0 with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY ZGt� Tel. No. 9,/ G� LICENSED CONTRACTORS DECLARATION LICENSE OR Disp. Room Air Cond. REG. NUMBER Class.e z(�/ I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY d and Professions Code,and my license is in full force and effect. - � p �A Size &Type HP, KW, KVA, or KVAR v " �Q 0 O 7rr���% License Number 1 ZLic. Class C ' 0 Up to 1 Incl. FINAL U Contractor To�7�)�A I r" 3 r "/ 3 Over 1 to 10 Incl. DATE Cr Date VALIDATION ❑ Over 10 to 50 Incl. � FINAL U I am exempt under Sec. Over 50 to 100 Inc. BY LU B.&P.C. for this reason Over 100 a- Services, Swbd., MCC& Panelboards Poo. 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 ; I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section Business anSecti7031.5, d Additional Sign Branch Circuits r- Professions Code): ;a€ r7o tl ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Oth (See Comp to Fe dule)_ , �TF?,:� Business and Professions Code). f C� Z __� n( 2_ _p'_gpp CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for I.,ML the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) �Lf a (Sec..3097, Civ. C.). .fJ NGE t j PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE Lender's Address I certify that I have read this application and state that the TOTAL FEE a !30r.? t r„ i i ¢ above information is correct. I agree to comply with all County -- ordinances and State laws regulating Electrical wiring, and her y authorize representatives of this County to enter upon the bove-men property for inspecti n purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE c �g i ©5 ignot of Per a Date