HomeMy Public PortalAbout5546 ALESSANDRO AVE_Electrical__ WORKERS COMPENSATIONcate o cons) CE 863 1CVB, APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE 8066
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
ora certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished EACH NO FEE ADDRESS
PY Y New Residential Bldgs & Pools
Certified copy is filed with the county building mspec 1 & 2 Family Sq Ft $ — $ LOCALITY
tion department Multi family Sq Ft — NEAREST �}
Residential Swimming Pools CROSS ST
OWNER OR
Date Applicant JJFIRM NAME �-
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec ..���Light�Sw 3 MAIL 1
COMPENSATION INSURANCE First 20 f j DDRESS 1 `
(This section need not be completed if the work involved by Total No Additional CITY Tel No
the permit is for one hundred dollars ($100)or less )
1 certifythat n the performance of the work for which this PLAN CHECK
iP i APPLICANT
permit is issued I shall not employ any rson any manner
so as to become subject to the Worker Com e/n a on ws Lighting Fixtures First 20 ADDRESS
Total No Additional
_as CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If aft making this Certificate of APPLICANT
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 — ADDRESS
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 LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO PRO SED BY
ff }
and Professions Code and my license is in full force and effect
jZ
Size & Type HP KW KVA or KVAR to Q
License Number Lic Class Up to 1 Inch FINAL
09
Over 1 to 10 Incl DATE VALIDATION Q
Contractor Date Over 10 to 50 Incl
QFINAL V
I am exempt under Sec Over 50 to 100 Inc BY W
a
B &P C for this reason Over 100
Date Services Swbd MCC& Ponelboards
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
Over 1000 Amp or
Exemption for Reg Maint Elect Over 600 V ! /
SINGLE FAMILY Temp Power P edl & Appurtenances
HOME OWNER BUILDER DECLARATION 1 5 1 5 A
Sign with One Branch Circuit
I hereby affirm that I am exempi from the Contractor s License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and # o 0 0 0 0 2
Professions Code) l
M sc Conduits 8 Conductors
as owner of the property will do the work and the � 2 0 0 4 1 7 5
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044 Business and Professions Code) Q , o 0 0 145
CONSTRUCTION LENDING AGENCY
S25-84
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
P Lender s Name
' PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
above inf motion is correct I agree to comply with all County
ordmanc and State laws regulating Electrical wrong and
hereby thorize re esent tives f This County to enter upon
the abo a menti d pro ert f r inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnatur f ermit ee Date