HomeMy Public PortalAbout5329 ALESSANDRO AVE_Electrical__ WU�that I COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS 01
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
❑ 1 &2-Family,Sq.Ft.
Certified copy is filed with the county building inspection _ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK
PAGE 1PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR
Outlets:Rec.—Light Sw.
COMPENSATION INSURANCE FIRM NAME
✓ First 20 �'O�
(This section need not be completed if the work involved by the �` MAIL
Total No. Additional S l
permit is for one hundred dollars($100)or less.)
1 certify that in the performance of the work for which this permit CITY /O_ Tel.NZg7
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation w Lighting Fixtures �r First 20 APPLICANT
Total No.�-` Additional ADDRESS
Date r� Applicant
NOTICE TO APPLICANT: If, after making this 7Cper,,
ate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY Tel.No.
Exemption,you should become subject to the Worke t n OTHERAPPLIANCES NOT OVER 3 HP.rovisions of the Labor Code, ou must forthwith such PERMIT
p y
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. }
LICENSE OR O
Over 50 t0 100 Ind. REG.NUMBER
�� / v Over 100 DISTRICT NO. PrOSED BY V
License Number / �F Li C.Classes
v/ sServices,Swbd.,MCC&Panelboards I
Contractor /�L��date �ay�%97 0-399 Amp.Under 600 V FINAL DATE O
F-1 I am exempt under Sec. 400-1000 Amp.Under 600 V ° LU
Over VALIDATION
Over 1000 Amp.or Over 600 V FINAL Q
B.&P.C.for this reason BRANCH CIRCUIT FEES BY U)
Date: 15A,or 20A, 120V,Lighting or Recept. ^ Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch CircuitsIL
V
AC:C:T n,>•
❑ 41 Or More Branch Circuits ., i i 41 -,
Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits 3-603 1 T .30
1
SINGLE FAMILY Temp. Power Pole&Appurtenances ITEMS
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit TOTAL 4 -1 - 30
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): CHECK
41.30
ElCHANGI,as owner of the property, will do the work and the structure Misc.Conduits&Conductors E .00
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ' CHANGE V
and Professions Code). �1�t� �-`�t{t
CONSTRUCTION LENDING AGENCY 0000-0001 t c7/ 8/96
1 hereby affirm that there is a construction lending agency for the 4?7} 1 l, 1�,
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) 2.*3
Civ. C.)
PLAN CHECKING FEE
Lender's Name /y
PERMIT ISSUING FEE vh� C7
Lender's Address
I certify that 1 have read this application and under penalty of purjury state TOTAL FEE
that the 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 he above-mentioned property
for inspection urp ses. SEE REVERSE FOR EXPLANATORY LANGUAGE
L SIGNATURE OF PERMITTEE DATE