HomeMy Public PortalAbout5823 ALESSANDRO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0079 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I-have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereofe 38 0 Lab. C.)
Poli ompany FOR APPLICANT TO FILL IN JOB
❑ ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
— $ $ LOCALITY
Certified co is tiled ePTION
n eco 1 &2-Family,Sq.Ft. �
PY9 P NEAREST
departme Multi-family Sq.Ft.' CROSS ST.
Date AResidential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF WORKERS' Outlets:Rec._Light Sw. OWNER OR NAME
COMPENE FIRMFirst 20(This section need not beork involved by the MAIL
Total No. Additional ADDRESS
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY421 No. /y►
is issued, I shall not employ any person in any manner so as to PLAN CHECK (�J
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of EP CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. A 00
provisions of the Labor Code, you must forthwith comply with such PER IT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APP
LICENSED CONTRACTORS DECLARATION Size&Tye HP,KW,KVA,or KVAR ADDRESS /
1 hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY el.No '
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl.
Over 50 to 100 Incl. LICENSE OR f
REG.NUMBER Class. O
(x) Over 100 DISTRICT NO. P SED BY
License Number c. s —2 Q U
51-
Services,Swbd.,MCC&Panelboards �O c ==® T_
FINAL
Co ctZ l/p 0-399 Amp.Under 600 V&" DATE O
400-1000 Amp.Under 600 V Z_Z q_Q VALIDATION U
I exempt under Sec. Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Date: 15A,or 20A,120V,Lighting or Recept. z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
El
41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY ; »^
Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit a•:4}
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3 T F RIV3
Code):
E
IR`s j•-
El I,as owner of the property, will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ;L;I f''. 45.15
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.) y_S
PLAN CHECKING FEE _' ;i PIN, �'''
__. ... s I �.
Lender's Name
PERMIT ISSUING FEE a�
Lender's Address /
I certify that I have read this application and under p y of purjury state TOTAL FEE
that the above information is correct. I agree comply with all County
ordinances and St a laws regulating Electri wi g,and hereby authoriz
re tative this C my t n r on bove-mention prope y
or ins p , rpos / SEE REVERSE FOR EXPLANATORY LANGUAGE
v
G URE OF PERMITTEE TE