HomeMy Public PortalAbout5342 ALESSANDRO AVE_Electrical__ WORKERS' COMPENSATION DECLARATION -663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I herby affirm CE-Bose that I have a certificate of consent to self insure, C
or a cdrtificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. X81' Company 512E IRL4 FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS AtiMroaw ORD Nc-
1 & 2-Family, — LOCALITY
Certified, copy is filed with the county building inspection. y,Sq.Ft. $ — $ LES C! CA
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Date 14 ApplicantResidential Swimming Pools OWNER OR
CERTIFICATE OF EXEMPTION FRO WORKERS' FIRM NAME
Outlets:Rec Light � Sw. AIL She
COMPENSATION INSURANCE qg
ADDRESS
(This section need not be completed if the work involved by the First 20
permit is for.one hundred dollars ($100) or less.) Total No. Additional CITY Tel. No.
1 certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall not employ any person in'any manner so as to APPLICANT
become subject"to the Workers'Compensation Laws. Lighting FixturesFirst 20 ADDRESS
^
Total No. /1 Additional
Date Applicant 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'Compensation Range_ Heater_ D.W. _ APPLICANT 14AL /CPL �1o49.1DLI
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS w� (540al f VC,
provisions or this permit shall be deemed revoked. Top FAU W.H. CITY (,
LICENSED CONTRACTORS DECLARATION (j 6b Z
Hood — Fan _ Other_ �" C�lN Tel.No.
I hereby.affirm that I am licensed under provisions of Chapter 9' Dis — Room Air Cond. LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and p REG.NUMBER / 3 Class.Q
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROCESSED Bx
License Number CtI58`J / //1�,��,� Size& Type HP, KW,KVA,or KVAR -4-3107C 6�-�l
Lic.Class—1 Up to 1 Incl. FINAL /� U
Over 1 to 10 Incl. r, DATE —'yiI
Contractor Date 9 G/ VALI ION �
❑ Over 10 to 50 Incl. FINAL
I am exempt der Sec. Over 50 to 100 Inc. gY 2 fJ
W
B.&P.C.for this reason Over 100 ��� o v 1L
Services, Swbd.,MCC& Panelboar /] _
Date: 0- 200 Amp.Under 600 V � I!I •� t/ ® 3307 36o�°
Signature 201 - 1000 Amp. Under 600 V y '/
El Exemption
1000 Amp. or Over 600 V 1 ITEMS
Exemption for Reg.Maint. Elect. TOTAL
36 75
O
HOME OWNSINGL FAMIDECLARATION Temp.Power Pole & Appurtenances CHECK 36.75
DER
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits CHANGE .00
Code):
❑ I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors n ii••'' i•� 'I
1/ 4/39is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ tJi1'U` a
and Professions Code). 0081 1 AMID 12
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE )60
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
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
property fo in pection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE .
'Signature of Permittee Date