HomeMy Public PortalAbout5731 ALESSANDRO AVE_Electrical__ WORKERS'COMPENSATION DECLARATION CE 806G (2-80) APPLICATION OR ELECTRICAL-PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES ILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
FOR APPLICANT TO FILL IN JOBPolicy No. Company New Residential Bldgs.&Pools EACH NO.IV FEE ADDRES _ y� -i S_�j
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY—_(
❑ Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER OR /n
FIRM NAME
Date Applicant Outlets: Rea? ht �j(� MAIL
� Sw.
/ First 20 / ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Tel No.
COMPENSATION INSURANCE PLAN CHECK d
APPLICANT O
(This section need not be completed if the work involved U
Lighting Fixtures First 20
by the permit is for one hundred dollars ($100) or less.) ADDRESS �
Total No.
Additional O
I certify that in the performance of the work for which this CITY Tel No. (—
permit is issued, I shall not employ any person iFixed Appliances Not Over 1 HP U
n any manner PERMIT i^� �E )�� W
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT Q lfl, d
s
Oven _ Dryer_W.M._ ADDRESS VJ
Date. Z Applicant 2C. ��C Top FAU _W.H..^ �^
Hood _ Fan —Other CITY 1�� Tel No. C, '•-7'
NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond.— LICENSE OR ^ )) /
Exemption, you should become subject to the Workers' REG. NUMBER D6 Class C)
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PRO D BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW, KVA,or KVAR
Up to 1 Incl. O y
FINAL
Over 1 to 10 Incl. DATE 1�jl_e U VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc, FINAL
BY
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 "A
ness and Professions Code, and my license is in full force and
effect. Services
0-200 Amp- Under 600 V
License Number Lic. Class 201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits&Conductors
I, as owner of the property, will do the work and the
Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section 9 1 3 9. 1 A
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY # o o o 0 o 2
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is
issued(Sec. 3097,Civ.C.). PERMIT FEE (Sub-Total) 2 0 - 20.50
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) o o 0
20,509
Lender's Address PERMIT ISSUING FEE 07 2 (t-—"S U
I certify that I have read this application and state that the TOTAL FEE Q
above information is correct. I agree to comply with all County
ordinances and State laws ulating Electrical wiring, and
hereb authorize represen ti s of this County to enter upon
the aborrcerrtioned p y for inspection purposes. SEE-REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date