HomeMy Public PortalAbout5510 ALESSANDRO AVE_Electrical__ WORKERS' COMPENSATION DECLARATION '20-0019 DPW 3/87
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I he�iM by`affirm that'I Have a' CE_806 certificate of consent to self 76A66G APPLICATION FOR ELECTRICAL PERMIT
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
FICertified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE .ADDRESS
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ _ $ LOCALITY 7101hC
tion department. Multi-family Sq. Ft. NEAREST
CROSS ST. We V
Date Applicant Residential Swimming Pools OWNER OR
/ FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' y (p MAIL
COMPENSATION INSURANCE Outlets: RecLight Sw._
ADDRESS S
(This section need not be completed if the work involved by First 20 g CITY Tel. No.
the permit is for one hundred dollars ($100)or less.) Total No. Additional e
PLAN CHECK
I certify that in the performance of the work for which this ,l APPLICANT
permit is issued, I shall not employ any person in any manner First rs
Lighting Fixtures 20 v ADDRESS
so aAtob coe subject to the Workers'Compensation Laws. D
Total No.
WA/4
n Additional
CITY
ija���/" e Tel. No. 8 Q
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION
Exemption, you should become subject to the Workers' Range— Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS175
with comply with such provisions or this permit shall be Top FAU —W.H. — 49 b
deemed revoked. Hood Fan —Other CITY `� Tel. No. 6yk
LICENSED CONTRACTORS DECLARATIONICENSE OR
Disp. — Room Air Cond. Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. rQ / PROCESSE BY a
and Professions Code, and my license is in full force and effect. (f b
Size&Type HP, KW, KVA, or KVAR O
License Number Lic. Class _� Up to 1 Incl. h' FINAL
L Over 1 to 10IncH�P DATE , VALID ION W
Contractor Date Over 10 to 50 Incl. O
FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 In, 11
Services, Swbd., MCC & Ponelboards ® 7 V
Z
Date: Z
0- 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V 03 3.3 A
ElExemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V #'e o,e 0'0,2
SINGLE FAMILY Temp. Power Pole & Appurtenances ;d o?o 6 &0 0
HOME OWNER-BUILDER DECLARATION
I herebyaffirm that I am exempt from the Contractor's License Sign with One Branch Circuit =
Law fothe following reason (Section 7031.5, Business and Additional Sign Branch Circuits o-o:6.6 a.0,0,0
Professions Code): 0 8.'0 2."8
L'J I, as owner of the property, will do the work and the Misc. Conduits &Conductors
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_
Business and Professions Code). 'n d12
CONSTRUCTION LENDING AGENCY M 2
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)
(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 lows regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Dbte