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Home My Public Portal About5926 ALESSANDRO AVE_Electrical__ .��, �` RKERS' COMPENSATION DECLARATION 20:0019 DPW 3/87 '1ere6y�pftirm that I hdveia`cerfificate of consent to self CE806G APPLICATION FOR ELECTRICAL' PERMIT O insure, or d certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy th f-(Sec.,3800, Lab. C. Policy No Company FOR APPLICANT TO FILL IN JOB fled copy'is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 7 ❑Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY _ 9 tion department. e Multi-family Sq. Ft. / NEAREST //fir Residential Swim Po s CROSS ST, lj . Date Applicant �' '� �G g OWNER OR I� � FIRM NAME 40 G CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Re� Light Sw.— MAIL --y COMPENSATION INSURANCE ADDRESS / © � Total No. C y.py� (This section need not be completed if the work involved by Additional First 20 CITY Tel. No. 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 so as to become subject to the Workeis'Compensation Laws. Lighting Fixtures First 20 ADDRESS Additional Total No. CITY Tel. No. Date Applicant r NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT APPLICATION Exemption, you should become. subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — ab� deemed revoked. CITYTel. o. J LICENSED CONTRACTORS DECLARATION Hood — Fan —Other Disp. — Room Air Cond. _ LICENSE OR ER f7 T�(y Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY �- and Professions Code,and my license is in full force and effect. , l d ze &Type HP, KW, KVA, or KVAR �J 0 License Number ��7/� tic. Class \y3 Up to 1 Incl. FINAL U Contractor ` ez� Date Over 1 to 10 Incl. DATE0) (1 VALIDATION 0 Over 10 to 50 Incl. FINAL VVV ❑ 1 am exempt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 10014� IZ Date: Services, Swbd., MCC& Ponelboards z Z 0-200 Amp. Under 600 V — Signature. 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V SINGLE FAMILY HOME OWNERTemp. Power Pole&Appurtenances 2 -BUILDER DECLARATION I hereby affirm that I am exempt from the.Contractor's License Sign with One Branch Circuit ACCT.14 Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits yy Professions Code): 3307 391.65 ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors 1 ITEM structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , TOTAL 39 1. _ c Business and Professions Code). CONSTRUCTION LENDING AGENCY CHECK 391.65 1 hereby affirm that there is a construction lending agency for CHANGE .Cd the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) / J (Sec. 3097, Civ. C.). PLAN CHECKING FEE M Lender's Name —WO1 6/ 9/89 PERMIT ISSUING FEE Lender's Address .16 3879 1 AM10:51 I certify that I have read this application and state that the a,TOTAL FEE above information is correct. I agree to comply with all County s ordi a and State laws regulating Electrical wiring, and eby thorize representatives of this County to enter upon h ave-menti a prop rt for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ig ature of Permittee Date ©s