HomeMy Public PortalAbout5502 ALESSANDRO AVE_Electrical__ toPOthat I 76A663 COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I he�eby affirm that have a certificate of consent to self insure, ,
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.) e
Policy No. J� Company �L « FOR APPLICANT TO FILL IN JOB
ADDRESS �d
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
$ $ LOCALITYfj7AL ,
Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. .4-
1 department. _ Multi-family Sq.Ft. NEARE ST.
Date `� Applicants Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCCE1L
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWN
COMPENSATION INSURANCE NAME
(This section need not be completed if the work involved by the First 20 MAIL
permit is for one hundred dollars($100)or less.)
Total No. Additional ADDRESS �-Z-/ y �feU
I certify that in the performance of the work for which this permit CITY Tel.No.
is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 PLAN CHECK
1 p 9 APPLICANT
Total No. Additional
- ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT-: If, after making this Certificate of CITY Tel.No.
Exemption, you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked.
Power Apparatus&Large Appliances APPLICANT 1rL -7'ICt� 7, ? G
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR 9 ADDRESS//
,3,, 0
1 hereby affirm that I am licensed under provisions of Chapter 9n/ Over 3 to 10 Incl. I / r `
(commencing with Section 7000) of Division 3 of the Business and . CITY / j/+ Qf� Tel.No3`
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. , }
LICENSE OR ��� Class.
Over 50 to 100 Incl. REG.NUMBER C—�Q
CIL
Over 100 DISTRICT NO. PR _ ESSED BY Q
License Number Lic.Class V
1 4 Services,Swbd.,MCC&Panelboards ���U may!`
Contractor�� �' `� � Date '� / _/ 0-399 Amp. Under 600 V FINAL 0
DATE
El400-1000 Amp. Under 600 V Vi ]q,Q
I am exempt under Sec. r ci / VALIDATION V
Over 1000 Amp.or Over 600 V FINAL LU
B.&P.C.for this reason BRANCH CIRCUIT FEES co
BY a.
Date: 15A,or 20A, 120V,Lighting or Recept Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
ED41 Or More Branch Circuits
Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits .}
SINGLE FAMILY Temp.Power Pole&Appurtenances � T g
HOME OWNER-BUILDER DECLARATION ACC t o S
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit n�y 4ba7
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3,7
Code): 1 ITEMS
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL "Q m
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
70
and Professions Code). 46.70)
CHECK
CONSTRUCTION LENDING AGENCY CHANGE .00
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 0000-0001 4/11/96
Lender's Name "p~� 5853 1 AM 10,54
PERMIT ISSUING FEE Q
Lender's Address
I certify that I 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 the above-mentioned property
f pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-1���
SIGNATURE OF PERMITT158 DATE