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Home My Public Portal About5049 ALESSANDRO AVE_Electrical__ ! WORKERS' COMPENSATION DECLARATION A663 cocw3ie7 76APPLICATION FOR ELECTRICAL PERMIT O CE-66 I�h®reby 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, C.) Policy,,No.-[ ( T'SIQ Cdr i;6 E- O/�I (� FOR APPLICANT TO FILL IN JOB -47 ❑Certified copy is hereby furnished. V�� JJJ New Residential Bldgs. & Pools EACH NO. FEE ADDRESS �J�j ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-Aamily Sq. Ft. — NEAREST / CROSS ST. Date I-�o'C/? Applicant © �i U s6�ential Swimming Pools OWNER OR ' IRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light :F-Sw. MAIL COMPENSATION INSURANCE First 20 /' D ADDRESS (This section need not be completed if the work involved by Total No.-,.-/—d Additional CITY Tel. No. 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 Worker Compensate aws. Lighting Fixtures First 20 7.0 ADDRESS 3 Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP NOTICE TOAPPLICANT: If, after making this Certificate of PPPLICATION .1 IT Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven Dryer —W.M.— ADDRESS7� L� L with comply with such provisions.or this permit shall be Top FAU —W.H. — deemed revoked. Hood — FanOther— CITY �� - el. No. ' S LICENSED CONTRACTORS DECLARATION Disp. Room Air Cond. �, LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER �� Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PRQ5 SED BY and Professions Code,and my license is in full force and effect. r/ t1 5/3//3Size &Type HP, KW, KVA, or KVAR ,�O 0 License Number Lic. ClassU '''''JJ��yyyyy Up to 1 Incl. FINAL Contract �MS�rd Over 1 to 10 Incl. DATE `� v VALIDATION 0 ❑ Over 10 to 50 Incl. FINAL I- I am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 t1 Services, C & Panelboards , U) Date: 0- 2 Under 600 V Z Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. _ SINGLE FAMILY Appurtenances HOME OWNER-BUILDER DECLARATION Temp. Power Pole &A pp �>••-•- .� I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): Ell, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— Business and Professions Code). CONSTRUCTION LENDING AGENCY 1C 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). L Oy �� -� PLAN CHECKING FEE ' Lender's Nameoff _i„i E....UL-;=w PERMIT ISSUING FEE 3F t i, u Lender's Address___!0 I certify that I have read this application and state that t OTAL FEE above information is correct. I,agree to comply with all Co my ordinances and State laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon t ov -mentioned operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE u/L S . / '1�� ©: Signature of Permittee Date