HomeMy Public PortalAbout5720 ALESSANDRO AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76A663 10/81APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have*a certificate of•consent to self insure CE-A,06G
or a certificate-crf Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof (Sec. 3800.Lab.C.)
Policy NO. Company FOR APPLICANT TO FILL IN JOB
❑ ADDRESS
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE LOCALITY
Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ — $
,department. Multi-family Sq.Ft. — NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR ,_a
FIRM NAME .
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Re-,- L4 Sw. "/ MAIL
COMPENSATION INSURANCE ® ADDRESS
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars($100)or less.)
Total No. � Additional CIT ,�, Tel No.
I certify that in the performance of the work for which this permit APPLICANT PLAN CHEC '
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
114
Additional lbt IOU
Date Applicant
Total No. CITY Tel.No.NOTICE A PLICANT: If, .after making this Cer of fixed Appliances Not Over 1 HP PERMIT r
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven Dryer J_? W.M._ ADDRESS .'
provisions or this permit shall be deemed revoked. Top FAU _ W.H. ,
LICENSED CONTRACTORS DECLARATION Hood Fan _ Other_ CITY164 el.No.
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR r
DiSp. ROOM Air Cond. REG.NUMBER J Class.
(commencing with Section 7000) of Division 3 of the Business and 0
Professions Code,and my license is in full force and effect. DISTRICT PRO ED.
Power Apparatus& Large Appliances �
/ Size& Type HP,KW,KVA,or KVAR
a�
License Number-T �b_ Lic.Class Up to 1 Incl. FINAL V
Cont racJ2�gA�l ate a Over 1 to 10 Incl. DATE VALIDATION O
❑ Over 10 to 50 Incl. FINALr,,W ~
I am exempt under Sec. Over 50 to 100 Inc. By Vf f 0
B.&P.C. for this reason Over 100 -� Cn
Services,Swbd.,MCC & Panelboards Jti/p
Date: 0- 200 Amp.Under 600 V lip (J�/
Signature 201 - 1000 Amp.Under 600 V
❑
Exemption for Reg. Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole& Appurtenances �?
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): 3307 121 o 601
I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors 1 1fEMS
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _
and Professions Code). ► TOTAL „ 1,030
CONSTRUCTION LENDING AGENCY CHECK 120.80
1 hereby affirm that there is a construction lending agency for the tai t
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHANGE o00
Civ. C.).
PLAN CHECKING FEE
Lender's Name 13000-000 1 3/19/90
PERMIT ISSUING FEE �t�ty i 1 �M10:58 Lender's Address 11
1 certify that I have read this application and state that the above TOTAL FEE
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 for inspection pure S.
e � SEE REVERSE FOR EXPLANATORY LANGUAGE • ,
Signature of Permittee Date