HomeMy Public PortalAbout5514 ALESSANDRO AVE_Electrical__ WORKERS COMPENSATION DECLARATION 720 6A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O
I Hereby affirm that I have a certificate of consent to self CE 806G
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 /r ( q
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS `� ►"V
Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ — $
LOCALITY
tion department Multi family Sq Ft NEAREST
CROSS ST o )4
Residential S immin Pools p
Date Applicant g ORM NAME
4 CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light
"2_ F1
� MAIL y�
COMPENSATION INSURANCE, S ADDRESS G `�
This section need not be completedFirst 20
( if the work involved b Y Total No Additional CITY G Tel No —
the permit is for one hundred dollars ($100)or less ) PLAN CHECK
I certify that in he performance of the work for which this 14PPLICANT
permit is issued I shall not employ any person in any manner
so as to be ome subjectito the Workersmpensation Laws Lighting Fixtures/ First 20 577—
ADDRESS
/� Additional
Date o Applicant-,49 / Total No CITY Tel N
NOTICE TO APPIf after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
ExemptiLICANT on you should become subject to the Workers Range— Heater—D W — APPLICATION
Compensation provisions of the Labor Code you must forth Oven — Dryer —W M — ADDRESS QJ
with comply with such provisions or this permit shall be Top — FAU —W H —
deemed revoked Hood — Fan —Other— CITY Tel No
LICENSED CONTRACTORS DECLARATION Disp — Room Air Cond — LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER Class
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROCESSED
and Professions Code and my license is in full force and effect / CL
Size &Type HP KW KVA or KVAR f 0
License Number Lic Class0
Up to 1 Incl FINAL f5
Contractor pate Over 1 to 10 Incl DATE _� Y VALI T Cr
Over 10 to 50 Incl FINAL �.�%
I am exempt under Sec Over 50 to 100 Inc 0
BY U
` W
B &P C for this reason Over 100 11 Z
L
Date Services Swbd MCC& Panelboards 0 8 A Z
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V # o e o to 0 2
OExemption for Reg Maint Elect Over 1000 Amp or Over 600 V ( o - 1 95,0
SINGLE FAMILY Tem Power Pole &Appurtenances x
HOME OWNER BUILDER DECLARATION p pp o o 0 1 9 5 0 CE
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits 0 928,-88
Professions Code)
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) pop. /
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 PERMIT FEE (Sub Total)
(Sec 3097 Civ C ) / -
PLAN CHECKING FEE
Lender s Name r _
PERMIT ISSUING FEE J
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 J
hereby authorize representatives of this County to enter upon
the ab v mentipprEd property for inspects n urpose
f/ � qi/,p-�� SEE REVERSE FOR EXPLANATORY LANGUAGE
24A / !�0 Os
igna ure of Permittee Date
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