HomeMy Public PortalAbout5740 ALESSANDRO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
1 hereby affirm that I have a certificate of consent to self insure, ,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab. C.) SEI
Policy NO. Company FOR APPLICANT TO FILL IN JOB
ADanAro Ave-
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
❑ dentgs. oo
$ $ LOCALITY e%,A9J.1?_Ci
Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft.
PY Y 9 P —
department. Multi-family Sq.Ft. NEAREST CROSS ST. wey,KVA"V,
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR2
er� 0
ki
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by the MAIL
permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS
I certify that in the performance of the work for which this permit CITY Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
`I ADDRESS
X Dat pplicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
/\NOTICE T APPLICANT: If, afte making thi rtificate of CITY Tel.No.
Exemption,you should become sub' t to the Worker Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
G
provisions or this permit shall be deemed revoked.
Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS - c-j'I rO ,e
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. /1
(commencing with Section 7000) of Division 3 of the Business and CIT V Tel.Nqf O S 9
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. / }
LICENSE OR Class. a
Over 50 to 100 Incl. REG.NUMBER
Over DISTRICT NO. PR SED BY
License Number Lic.Class 0
Services,Swbd. MCC&;bo ds
0-399 Am Under6010~ FINAL
Contractor Date 6 p' / � DATE F-
400-1000 Amp.Under 600 V U
El VALIDATION I am exempt under Sec. W
Over 1000 Amp.or Over 600 V FINAL 101-
B.&P.C.for this reason BRANCH CIRCUIT FEES BY W
Date: 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits N—Y
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits _ r9
SINGLE FAMILY Temp. Power Pole&Appurtenances — r
HOME OWNER-BUILDER DECLARATION I'-;i•Zj
S
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits j i_t;AL
63 - 45
Code):
CHUX
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors ,..i
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t• IAN L
and Professions Code).
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the ii it :•.�
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) j Ail
Civ. C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE �r0
Lender's Address ,
I certify that I have read this application and under penalty of purjury state TOTAL FEE �� L�, /
that the above 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 in pe - purposes. _ SEE REVERSE FOR EXPLANATORY LANGUAGE
C
S TUBE OF PERMITTY DATE