HomeMy Public PortalAbout5846 ALESSANDRO AVE_Electrical__ �I WORKERS COMPENSATION DECLARATION 76A663 10/81
806G APPLICATION
APPLICATION FOR ELECTRICAL PERMIT
'C he•&_ affirm that I have a certificate of consent to self
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUIL ING AND SAFETY/ '
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or a certified copy thereof (Sec 3800 Lob C ) I �� t
Policy No Company FOR APPLICANT TO FILL IN JOB
a 41'
Certified co is hereby furnished EACH NO FEE ADDRESS a ✓GC I' ��
PY Y New Residential Bldgs 8 Pools �^ f
1 & 2 Family S Ft $ — $ LOCALITY _TC► , ` `
Certified copy is filed with the county building inspec Y 9
tion department Multi family Scl Ft NEAREST
ST
Date Applicant Residential Swimming Pools �1 t i` CROSS OWNER OR
' FIRM NAME (41
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw_ MAIL CC
COMPENSATION INSURANCE ti� l ADDRESS o V ,
(This section need not be completed if the work involved by First 20+ , \
the permit is for one hundred dollars ($100)or less )
Total No Additio \` ��t CITY Tel Tel N
naho
PLA
I certify that in the performance of the work for which this \`�� , f 7i �{ �� A PLICANTK
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 i ' ADDRESS
9'0q-90Applicant
Total No Additional
�y CITY Tel No
Date ` pplicant � � Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after makin his Certifi to of PERMIT N7 + _ _L' ' C_ - -
Exemption you should become suble to the Workers - _ Range_ Heater_D W - _ 1 -
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M ADDRESS � 1 (t V�
with comply with such provisions or this permit shall be Top — FAU —W H —
deemed revoked Hood _ Fon _Other_ CITY�e Tel Noa
LICENSED CONTRACTORS DECLARATION Hoo
Air Cond — LICENSE OR Class
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ REG NUMBER
(commencing with Section 7000) of Division 3 of the Business power Apparatus 8 Large Appliances _ - DISTRICT NO _ P OCESS BY pr
and Professions Code and my license is in full force and effect
��3I d Size &Type HP KW KVA or KVAR 0 8 U
License Nu44
j� Lic Class
Up to 1 Incl FINAL fL'
Contractoro,1114W6 �fG� Date--R-o�-g� Over 1 to 10 Incl DATE � VALIDATION
Over 10 to 50 Incl FINAL�/ / W
I am exempt under Sec Over 50 to 100 Inc BY /''�-�
B &P C for this reason Over 100 Z
Date Services Swbd MCC& Ponelboards / l
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V
❑ Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V
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 for the following reason (Section 7031 5 Business and Additional Sign Branch Circrcuits
Professions Code)
Misc Conduits & Conductors
I as owner the property will do the work and the Other (See Complete Fee Schedule)_
structure is not
t intended or offered for sale (Section
7044 Business and Professions Code) 5 3 8 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for # • a a • • 2
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) • - 25,50
(Sec 3097 Civ C )
PLAN CHECKING FEE - • x 25505
Lender shame
Lender s Address /'
PERMIT ISSUING FEE 0 0 9 4"8 6
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 mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
_!6M_VX M4 A
Signature of P rmittee bote