HomeMy Public PortalAbout5934, 5934 1/2 ALESSANDRO AVE_Electrical__ WORKERS COMPENSATION DECLARATION 63 10/81
CE 8066
APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have~a certificate of consent to self CE 8
insure or a certificate of Workers Compensation Insurance } COUNTY OF LOS ANGELES BUILDING AND AFETYr
ora certified copy thereof (Sec 3800 Lab C ) I C.J N3f'
Policy No Company FOR APPLICANT TO FILL IN JOB
Certified co s hereby furnished E=CHFEE ADDRESS
PY Y New Residential Bldgs & Pools
❑ 1 & 2 Family S Ft !4D $ p LOCALITY T9l/L p lCertified copy is filed with the county building inspec Y qtion department Multi family Sq Ft NEARESTResidential Swimming PoolsCROSS STDate ApplicantOWNER M � IAJ J`p FIRM NAMECERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec�Light ZySw�� MAIL
COMPENSATION INSURANCE / ADDRESS
(This section need not be completed if the work involved by � First 20
the permit is for one hundred dollars ($100)or less ) Total Nob AdditionalCITY Tel
that in the performance of the work for which this PLAN CHECK
I certify P APPLICANT
permit is issued I shall not employ any person in any manner i
so as to become subject to the Workers Comensatio Laws Li hting Fixtures First 20 ADDRESS
Total No A0 Additional
CITY ft Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT "gyp
NOTICE TO APPLICANT If after making thiEMCertificate of APPLICANT
Exemption you should become subject to the Workers Range_ Heater_D W
Compensation provisions of the Labor Code you must forth Oven _ Dryer M — ADDRESS 6?8 g
with comply with such provisions or this permit shall be Top FAU W H —
deemed revoked CITY Tel No
LICENSED CONTRACTORS DECLARATION Hood Fan _ Other_ �t.
Disp Room Air Cond LICENSE t�2 Class �j[J
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER
�7i�(J� J
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROCES D BY r }
and Professions Code and my license is in full force and effect d
Size &Type HP KW KVA or KVAR �(� O
License Number `��J Lic Class Up to 1 Incl FINAL / V
y— 1 Over 1 to 10 Incl DATE �/r ? U/ VALIDATION
Contractor Date 1 Over 10 to 50 Incl (J C / V
F1FINAL
I am exempt under Sec Over 50 to 100 Inc BY LU
B &P C for this reason Over 100 n h
Services Swbd MCC & Ponelboards "dC Z
Dat 0 200 Amp Under 600 V , .–
Signature _ 201 1000 Amp Under 600 V
F-1Exemption
1000 Amp or Over 600 V
Exemption for Reg Maint Eject
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 Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and
Professions Code)
❑ I as owner of the property will do the work and the Misc Conduits & Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ;§072 1 A
7044 Business and Professions Code) ►'"
#} oko 0 0 02
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 2`0,'o 9(3 1 0
0 0
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) p� i
(Sec 3097 Civ C ) Q s i ra o 09611 0 v
PLAN CHECKING FEE t '
Lender s Name , 0� 2'4 -8 4
PERMIT ISSUING FEE v
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 jaws regulating Electrical wiring and
hereby authorize re resentat ves of this County to enter upon
the above mentio d pro y for inspection purposes
�_ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature Pe it ee Date r