HomeMy Public PortalAbout5939, 5939 1/2 ALESSANDRO AVE_Electrical__ WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab. C.) f
Policy No. Company FOR APPLICANT TO FILL IN JOBADDRESS �!/�� t�L .� ✓aLr7
Certified copy is hereby furnished. New Residential Bldgs. &Pools NO. EACH FEE
El
Certified copy is filed with the county building inspection 1 &2-Family,Sq. Ft. $ $ LOCALITY
NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OWNER OR
COMPENSATION INSURANCE g FIRM NAME
(This section need not be completed if the work involved by the First 20 MAILTotal No. Additional ADDRESS
permit is for one hundred dollars($100)or less.)
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 to PLAN
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
AddCHECK
Total No. ition
ADDRESS
al
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making 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 PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
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 CITY Tel.No. d
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl.
LICENSEClass.
Over 50 to 100 Incl. REG.NUMBB ER 0
License Number Lic.Class
Over 100 DISTRICT NO. PROCESSED BY W
J
Services,Swbd.,MCC&Panelboards LL
Contractor Date 0-399 Amp. Under 600 V FINAL❑ DATE Q
I am exempt under Sec. 400-1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V FINAL VALIDATION Q
B.&P.C.for this reasonBRANCH CIRCUIT FEES BY 0
Date: 15A,or 20A,120V, Lighting or Recept.
1 To 10 Branch Circuits W
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
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
❑ I, as owner of the property, will do the work and the structure Misc.Conduits&Conductors.
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Sctodule) ►
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
I Lender's Address
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 purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PERMITTEE DATE