HomeMy Public PortalAbout5318 ALESSANDRO AVE_Electrical__ WORKERS COMPENSATION DECLARATION CE 863 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE 8066
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN , JOB
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS p/ e S Y
S — C� f
Certified copy is filed with the county building inspec 1 & 2 Family q Ft $ $ LOCALITY e )11
tion department Multi family Sq FtNEAREST
Residential Swimming Pools '- CROSS STPa4 6
/
Date Applicant FIRM NAME '
OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERSOutl / ! MAIL
ets Rec /—Light_Sw
COMPENSATION INSURANCE First 20 :*.-ADDRESS
(This section need not be completed if the work involved by Total No ✓ Additional CITY �7 `Tel No �7_3
the permit is for one hundred dollars (:100)or less ) PLAN CHECK
1 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 Wor ers Compensation Laws Lighting Fixtures First 20 ADDRESS
Total No Additional
Date Applicant L CITY ' Tel No
NOTI E TO APPLICANT If after along this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the'Workers Range=Heater—D W APPLICANT
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W H
deemed revoked Hood — Fan _Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATIONOR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp — Room Air Cond -- R GLICENSE NUMBER Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCE ED BY
and Professions Code and my license is in full force and effect Power Apparatus& Large Appliances _ d
Size &Type HP KW KVA or KVAR U 0
FINAL tJ
License Number Lic Class Up to 1 Incl DATE �. OC
Contractor Date Over 1 to 10 Incl VALIDATION 0
F-1 Over 10 to 50 Incl FINAL .� ~
v
I am exempt under Sec Over 50 to 100 Inc BY
B &P C for this reason Over 100 Z
Date
Services Swbd MCC& Panelboards L ► —
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V
ElExemption
1000 Amp or Over 600 V
Exemption for Reg Maint Elect I
SINGLE FAMILY Temp Power Pole &Appurtenances
HOME OWNER BUILDER DECLARATION Sign with OnetBronch Circuit :9 2 0 5 5 A
I hereby affirm that I am exempt from the Contractor s License Additional Sin Branch Ci
Law for the following reason (Section 7031 5 Business and gCircuits # o 0 0 o o 2
Professi ode)
I as owner of the property will do the work and the Misc Conduits&Conductors 2)- 0 3 1 25
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ o 0 0 3 1 2 5=
7044 Business and Professions Code) I U
CONSTRUCTION LENDING AGENCY 06 1 8J-84
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) Q
(Sec 3097 Civ C )
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
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
theo e mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign re of Permittee Date