HomeMy Public PortalAbout6013 ALESSANDRO AVE_Electrical__ WORKERS COMPENSATION DECLARATION CE 863 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of con ent to self CE B06C' �
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) r
Policy No Company FOR APPLICANT TO FILL IN JOB /1
Certified co is hereby furnished EACH NO FEE ADDRESS (�
PY Y New Res dentia) Bldgs & Pools
❑ 1 & 2 Family S Ft $ _ $ LOCALITY
Certified copy is filed with the county building inspec Y 9
tion department y Sol Ft NEAREST
Multi familS
� _ CROSS ST
Date A licant Residential Swimming Pools OWNER OR .,J
PP � FIRM NAME
L CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec�Light�Sw MAIL
COMPENSATION INSURANCE ADDRESS ,
First 20
(This section need not be completed if the work involved by Total No Additional l CITY JJ, r Tel No
the permit is for one hundred dollars ($100)or less ) PLA ECK
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 Workers Compensation Laws Lighting Fixtures 0 First 20 ADDRESS J
Additional
Total No � CITY Tel No
/etDate pplicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT If after�k, is Certificate of PERMIT
Exemption you should become subject to the Workers Range_ Heater_D W 77WAPPLICANT
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
deemed revoked / CITY Tel No ,_ ` 7
Hood Fan _ Other_
LICENSED CONTRACTORS DECLARATION LICErIS OR SIJ
I hereby affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond REG NUMBER Class 1.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCESSED BY
and Professions Code and my j� ense is in full force and effect Power Apparatus& Large Appliances
Size & Type HP KW KVA or KVAR d
License Number V
Lic Class �� Up to 1 Incl FINAL - O
ji
ce
Contractor VALIDATION Q
Over 1 to 10 Incl DATE /�— //�� 0
e �/
Over 10 to 50 Incl FINAL V
I am exempt under Sec Over 50 to 100 Inc BY
Over 100 d
B&P C for this reason h j1�� ���A/ H
3 Services Swbd MCC & Ponelboards I 10, � ���� ✓J
Date 0 200 Amp Under 600 V J
Signature �)t !- � - � � 201 1000 Amp Under 600V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect
SINGLE FAMILY Temp Power Pole& Appurtenances <4 5 48 A
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit # e o o o o 2
1 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 2 0 0 2350
Professions Code) 1
❑ I as owner of the property will do the work and the Misc Conduits &Conductors o oto 23505
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)— 7-83
00 0
7044 Business and Professions Code)
61
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 PERMIT FEE (Sub Total) -
(Sec 3097 Civ C )
PLAN CHECKING FEE ®j
Lender s Name
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE y
above information is correct I agree to`comply with all County
ordinances and State laws regulating Electrical wiring and L
hereby authorize representatives of this County to enter upon
th ibove mentionj property pr inspection rposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signa r Permittee Dote' G