HomeMy Public PortalAbout5538 ALESSANDRO AVE_Electrical__ r la'.'
ORI(ERS COMPENSATION DECLARATION 200019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O
t irm that I have a certificate of consent to self �CEA806G
n ure ora certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES, / DEPT OF PUBLIC WORKS
or a certified copy thereof (Sec 3800 Laab
Policy No add S"G7ompany `+�+ FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished New Residential Bidgs & Pools EACH NO FEE ADDRESS
ertrfied copy is filed with the county building rnspec 1 & 2 Family Sq Ft $ — $ LOCALITY /� !
Cion department Multi family Sq Ft — NEAREST
CROSS ST
Residential Swimming Pools OWNER OR
Date Applicant QQ' FIRM NAME
CE TIFICATE OF EXEMPT FROM WORKERS Outlets Rec�Light�Sw MAIL OV6
COMPENSATIO INSURANCE First20 ADDRESS nn /
(This section need not be completed if the work involved by Total No 15'4 Additional CITY Tel No
the permit is for one hundred dollars ($100)or less ) a PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS
Additional
Date Applicant Total No 116
CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the Workers Range— Heater—D W — APPLICATION
Compensation provisions of the Labor Code you must forth Oven — Dryer L W M — ADDRESS Q !w
with comply with such provisions or this permit shall be Top — FAU -lL W H —
deemed revoked Hood Fan —Other_ CITY LC—PZ Tel No �IW—,?17
LICENSED CONTRACTORS DECLARATION Das — Room Air Cond LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 p REG NUMBER f 5/0 Class -2j
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO�'� PROCES ED BY >-
and Professions Code and my license is in full force and effect �� (/ 0-
Size &Type HP KW KVA or KVAR O
License Number �G/ c/17 Lic Class & Up to 1 Incl FINAL 3
0
Contractor! (b� Date Over 1 to 10 Incl DATE 4r V ATION 0
❑ Over 10 to 50 Incl FINAL ~
I am exempt under Sec Over 50 to 100 Inc BY C)
B &P C for this reason Over 100 0-
U)Date Services Swbd MCC& Ponelboards
0 200 Amp Under 600 V Z
Signature 201 1000 Amp Under 600V
0 8 2 6 A
Eli Oyer 1000 Amp or Over 600 V 2
Exemption for Reg Moint Elect # ° °to ° °
SINGLE FAMILY Temp Power Pole &Appurtenances ° ° 8000
HOME OWNER BUILDER DECLARATION
Sign with One Branch Circuit -
I hereby affirm that I am exempt from the Contractor s License Sigo s o 80005
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits
� Professions Code) ( a 0(I,a$
❑ 1 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) polo
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for I
the performance of the work for which this permit is issued PERMIT FEE (Sub Total)
(Sec 3097 Civ C ) 1
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE
Lender s Address t �
I certify that I have read this application and state that the TOTAL FEEG'Q
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring and r
hereby authorize representatives of this County to enter upon
the above mentioned pr perty for ins ection purposes , SEE REVERSE FOR EXPLANATORY LANGUAGE
re of P matte T ate
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