HomeMy Public PortalAbout5801 ALESSANDRO AVE_Electrical__ Y'JORKERS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION
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1 hereby affirm that I have a certificate of consent to self insure, CE-806G l"1�'����+i�1i �'®� ®[1 �LE\yTR��/-�L �Gfl ��
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec..3800,1_a �,)
Policy No. r ✓ ' Company `�'� ' �� �` FOR APPLICANT TO FILL IN - - JOB •---^• (�,+�y/
❑ ADDRESS 1,5
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Certified copy is hereby furnished. New Residential Bldgs.& Poo15. EACH' NO. _ •.•.FEE _
Certified ycopy is filed with the countybuilding inspection 1 & 2-Family, Sq.Ft. $ - $
department. Multi-family Sq.Ft. CROSS Si.
Residential Swimming Pools OWNER OR
Date Applicant �" a FIRM NAME ` /�'"� .. f/j /1✓
CERTIFICATE OF EXEMPTION FROM WORKERS', y, Outlets:Rec ight YSw. MAIL
COMPENSATION INSURANCE ADDRESS.„
This section need not be com feted if the work involved the First 20
( p y CITY Tel.No.
permit is for one hundred,dollars($100).or'less.) t Total No. Additional -
I certify that In the performance of the work for which this permit PLAN CHECK
is issued, I shall not employ any person.in any manner, so as to } _. APPLICANT }
Lighting Fixtures First 20 ADDRESS
become subject to the.Workers'Compensation Laws. y 9 9 � - -- --
Additional
Total No- -. - -CITY--- Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT r
NOTICE TO APPLICANT: If, after making this Certificate of
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 _ W.M._ ADDRESS -
provisions or this permit shall be deemed revoked. _ - ___Top FAU . W.H.__-
. .. .CITY Tel:No.
LICENSED CONTRACTORS DECLARATION Hood Fan Other_ r.
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air-Cond. - � I 6Q LICENSE oR
(commencing.with Section 7000) of Division 3 of the Business and REG:'NOMBER' � Q--2- Class,
Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSED BY _
Power Apparatus.&.Large-Appliances,
Size & Type HP,KW,KVA,or KVAR 00
License Number02c;�_'�7C> Lid. Class Up to 1 Incl.. FINAL
"_Wo �, l� yJ -�!� Over 1 to 10 Incl... DATE 0
Contractor / J r] ALIDATION 0
❑ Over 10 to 50 Incl. FINAL V
am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100 CL
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Services, Swbd., MCC & Panelboards 1 1 6 8 A
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V a ° ° ° a 2
® Over 1000 Amp. or Over 600 V
Exemption for Reg.Maint.Elect. ( 2t50
SINGLE FAMILY' Temp. Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One'Branch Circuit e 1` v
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits 1. 17-6--�J
for the following reason (Section 7031.5, Business and Professions
Code):
Misc.Conduits & Conductors
I,as owner of.the property,will do the work and the structure Other (See Complete Fee Schedule) _
is not intended or offered for sale (Section 7044, Business
and Professions Code).
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)
Civ. C.).
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
and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspecti n rposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
5 nature ofWermitte6 j� Date