HomeMy Public PortalAbout5315 ALESSANDRO AVE_Electrical__ WORKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800, a . C.)
Company (iL/ �✓I�. 0
FOR APPLICANT TO FILL IN JOB
ADDRES
Policy o? O' ����d
` New Residential Bldgs.&Pools EACH NO. FEE i
Certified copy is hereby furnished. 7/7 O 1 &2-Family,Sq. Ft. $ — $ LOCALITY
Multi-family Sq. Ft. NEAREST
Certified copy is filed with the county building inspection CROSS ST _
depart ent. Residential Swimming Pools OWNER OR
FIRM NAME c(/
Date �� pplicant Outlets: Re Light Sw. l�� 13 ADDRESS `�ll
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No� Additional
CITY Tel No.
COMPENSATION INSURANCE
PLAN CHECK }
C'
en PPLICANT
(This section need not be completed if the work involved ��� 1
by the permit is for one hundred dollars Fixtures First 20 0
Fixed Appliances Not Over 1 HP
s ($100) or less.) ADDRESS
Total No. Additional
I certify that in the performance of the work for which this CITY Tel No. .Q
permit is issued, I shall not employ any person in any manner PERMIT { U
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. _ APPLICANT /L�� S `�� SGI=✓ 11,1
Oven Dryer_W.M. ADDRESS t1
Date Applicant Top _ FAU _W.H.,_ Z
Hood Fan _Other_ CITY t G Tel No.,
NOTICE TO APPLICANT: If,'after making this Certificate of Disp. Room Air Cond. LICENSE OR SC u
Exemption, you should become subject to the Workers' REG. NUMBER Class
.Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. P E BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW, KVA,or KVAR -!9f/
N J
Up to 1 Incl. o0
Over 1 to 10 Incl. FINAL
DATE 3 — � VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL �r
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY �-
ness and Professions.Code, and my license is in full force and
effect. Services
License Number.
SG i� 0-200 Amp. Under 600 V y�
Lic.Class �,��
201-1000 Amp. Under 600 V
Contractor i Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi-
Additional Sign Branch Circuits } 0 0 0 0"0 2
ness and Professions Code): 2 ° ° 1 9 0
Misc.Conduits& Conductors
I, as owner of the property, will do the work and, the Other (See Complete Fee Schedule)— o o'0 1 3.'9 O
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 2123-81
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
above 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�roperty for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
S' nature of Permittee Date