HomeMy Public PortalAbout5750 ALESSANDRO AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 10/81 APhL6CA` ON FOR ELECTRICAL 'PERMIT
I hereb•q affirm that I have a certificate of consent to self insure,
CE-806G
or a certificate of 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 ���0 /�,�Ec,®��A 1_'Q
❑ Certified co is hereby furnished. EACH NO., FEE ADDRESS A s o'v��c�
� PY Y New Residential Bldgs.&Pools
El Certified & 2-Family,Sq.Ft. $ — $ LOCALITY"� �p L� .re
Certified copy is filed with the county building inspection
department. Multi-family Sq.Ft. — NEAREST
CROSS ST. W
O µQ
Date Applicant Residential Swimming Pools OWNER OR
1.� FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS'' Outlets:Rec L Light Sw. MAIL
— g
COMPENSATION INSURANCE /v ADDRESS
(This section need not be completed if the work involved by the First 20ZZi
Total No. ditional CITY Tel.No.
permit is for one hundred dollars($100) or less.)
Ad
1 certifythat in the performance of the work for which this permit PLAN CHECK
P APPLICANT
is issued, I shall not;employ any person in any manner so•as to
become subject to the Workers' a Lighting Fixtures First 20 • ADDRESS
Total No. •13 Additional CITY Tel.No.
/
Date ( f Apph Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater-1_ D.W.
provisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M. ADDRESS A! /< tow
provisions or this permit shall be deemed revoked. Top FAU _ W.H.
Hood CITY +fes Tel.No.2��
Fan I Other_
LICENSED CONTRACTORS DECLARATION � � 492600
/ ��
I hereby affirm that I am licensed under provisions of Chapter 9 5 LICENSE OR A��^
Disp. Room Air Cond. REG.NUMBER G Q Class.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PRO ED BY
Size& Type HP,KW,KVA,or KVAR d b O O
License Number Lic.Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE /_ p VALIDATION x
Contractor Date Over 10 to 50 Incl. l C Q0
FINAL V
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
Over 100 L1.
BAP.C.for this reason (n
Services,Swbd.,MCC& Pan ar Dv ®
Date: 0- 200 Amp.Under 6
Signature 201 - 1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V
F-1
Exemption for Reg.Maint.Elect.
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 t:;_; _a
for the following reason(Section 7031.5,Business and ProfesNons Additional Sign Branch Circuits
Code):
❑ I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors � i I E"E
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). T iTt__ 9 rr �0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) Q `-HA N11E�
Civ.C.). 07
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I 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
reg atiee4ri I wiring, and hereby authorize
representatives o thi ounty t r the above-mentioned
prop pactio p os
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Date