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HomeMy Public PortalAbout5827 ALESSANDRO AVE_Electrical__ WORKERS' COMPENSATION DECLARATION DPW 3/87 76A663 APPLICATION FOR ELECTRICAL PERMIT O t-hereby 'affirm-.that I have a certificate of consent to self CE 806G ansure7'or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB �(/ -CSA��y�n r�, Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS.572-7 ILES Wo A Certified co is filed with the count buildin ins ec- 1 & 2-Family, S Ft. $ _ $ LOCALITY PY Y 9' P Y� 9� tion department. Multi-family Sq. Ft. NEAREST Residential Swimming Pools CROSS 5T. S Fs ? AS rl>P1 r Date Applicant OWNER OR q r / , /1 FIRM NAME y�li� C L. r f CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec15Light 3 Sw./ MAIL pZ LASS N?��D A� COMPENSATION INSURANCE �, ADDRESS S A � s n First 20 (This section need not be completed if the work involved by Total No. 2 Additional b0 3 CITY EM Tel. No. Z9�i9r the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS so as to become subject to the Workers'Compensation Laws. Total No. / Additional CITY Tel. No. Date Applicant NOTICE TO APPLICANT: If, after makingthis Certificate of Fixed Appliances Not Over 1 HP PERMIT /� /f Range— Heater D.W. APPLICATION �7Er�K4� L/,A A* Exemption, you should become subject to the Workers' Compensation provisions of the Labor Code, you must forth- Oven — Dryer J_-W.M.— ADDRESS S,?2-7 41_FSSAA1DRb AVF, with comply with such provisions or this permit shall be Top — FAU W.H. — deemed revoked. Hood — FanOther— CITY M LE- Cd Tel. No.9s% t/29s LICENSED CONTRACTORS DECLARATION 2 319CLICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. Pe O SSED BY and Professions Code,and my license is in full force and effect. 0_ Size &Type HP, KW, KVA, or KVAR �•/ ' G!�'st-t�� O License Number Lic. Class Up to 1 Incl. FINAL U Contractor Date Over 1 to 10 Incl. DATE �7�7 VALIDATION Q Over 10 to 50 Incl. 0 FINAL I am exempt under Sec. Over 50 to 100-Inc. U BY LLJ B.&P.C. for this reason Over 100 Z Services, Swbd., MCC& Panelboards Date: 0- 200 Amp. Under 600 V Signature 201 - 1000 Amp. Under 600 V OExemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances Sign with One Branch Circuit _-. -•• s, I hereby affirm that I am exempt from the Contractor's License :.: Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): 1, as owner of the property, will do the work and the Misc. Conduits& Conductors Y _ structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ HL, rl; f.� Business and Professions Code). !'- - � ,_,, CONSTRUCTION LENDING AGENCY is I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE ) �(� °-• I Il jS?� p p (Sub-Total v ,;,1 (Sec. 3097, 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 TOTAL FEE 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-me 'oned pro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 9-:z2-9/ ©5 i ature of ee Date