HomeMy Public PortalAbout5839 ALESSANDRO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm ehat I have a certificate of consent to self insure,
or a ce 6licate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy there(P(Sec.-3800 Lab. C.)
Policy No./aq+1—O111`/1471ompany a�7z47C' ���� FOR APPLICANT TO FILL IN JOB
ADDRESS p�
❑ NO. EACH FEE'
Certified copy is hereby furnished. New Residential Bldgs.&Pools LOCALITY$ $ �, /t;Ft
Sq. . �!°T
❑ —
Certified copy is filed with the county building inspection 1 &2-Family, NEAREST
department. Multi-family Sq.Ft. CROSS ST. TcyNr4�
Date 93 Applicant [/.C,` Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light 3 Sw. FFIIRM NAME A.P
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by theMAIL
permit is for one hundred dollars($100)or less.)
Total No.0 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 t0 PLAN CHECK
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 / APPLICANT
/� Total No. Additional ADDRESS
Date �1 —�72 Applicant v~ RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after ma Ing this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such P RMIT
provisions or this permit shall be deemed revoked.
Power Apparatus&Large Appliances PLICANT / UACs
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I 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 CITYe;:)��O� L, Tel.No. pgp_
tZF—
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR7 }
Over 50 to 100 Incl. REG.NUMBER,Q J�� Class. d
a 1 Over 100 DISTRICT NO. Pmzl_vr��
D BY O
License Number��p�- / Lic.Class Services,Swbd.,MCC&Panelboards �/ Cc
Contractor le ° E. 0" GyfN7d,Date 1? 0-399 Amp.Under 600 V FINAL 0
DATE U
❑ I am exempt under Sec. 400-1000 Amp,Under 600 V ?� l��� VALIDATION W
Over 1000 Amp.or Over 600 V FINAL d
B.&P.C.for this reason BRANCH CIRCUIT FEES BY U)
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
Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION 'ACC I °s
with One Branch Circuit
w
I hereby affirm that I am exempt from the Contractor's License Law Sig ^^ss E,-7 �-}
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 20 6 .05
Code):
T
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors
�f;.
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) s I AL. � � L0_ f
— i
and Professions Code). pop. 3_ I:
CONSTRUCTION LENDING AGENCY C' r G
L',..'�_ X111
I hereby affirm that there is a construction lending agency for the �''' !'3= `
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.) _
PLAN CHECKING FEE }-
(s; —i-_3U� :`
Lender's Name
PERMIT ISSUING FEE a� S CE.-_.,_-t' ; Y a
.i i Axl S: __
Lender's Address D
I certify that I have read this application and under penalty of purjury state TOTAL FEE
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 inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
,IGNATUPIP OF PERMITTEE DATE