HomeMy Public PortalAbout6029 ALESSANDRO AVE_Electrical__ WORKERS' COMPENSATION DECLARATION 76A663 APPLICATION FOR ELECTRICAL PERMIT DPW 3/87
I hereby affirm that I. have a certificate of consent to'.self CE 8066 O
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
F]Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS Z-5 G2
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. -- NEAREST
CROSS ST.
Residential Swimming Pools OWNER OR
P�
Date Applicant '' FIRM NAME c/L /7 Z�—
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�'' Light 6 Sw. _60 MAIL
ADDRESS
COMPENSATION INSURANCE First 20 W
(This section need not be completed if the work involved by Total No. Additional -31
CITY 7"'" Tel. No.
the permit is for one hundred dollars($100) or less.)
PLAN CH CK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any ma ner
so as to beco a sub* ct to the Work o sation aws. Lighting Fixtures First 20 ADDRESS
Additional
Total No. CITY Tel. No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certi icate of APPLICATION
Exemption, you should become subject to the Workers' Range— Heater—D.W. _
Compensation provisions of the Labor Code, you must forth- Oven — Dryer _L W.M. ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood — Fan —Other_ CITY Tel. No.
LICENSED CONTRACTORS DECLARATION O LICENSE OR
Disp. _ Room Air Cond. _ REG. NUMBER Class.
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCES D BY d
and Professions Code,and my license is in full force and effect. �(
Size &Type HP, KW, KVA, or KVAR t V 0
License Number Lic. Class Up to 1 Incl. FINAL 0
Over 1 to 10 Incl. DATE tY
V DATION 0
Contractor Date Over 10 to 50 Incl. U
FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 t1
Services, Swbd., MCC& Panelboards Z
Date: 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 Temp. Power Pole &Appurtenances o
HOME OWNER-BUILDER DECLARATION 9 9 0,�l.A
1 hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit z
Law for th .following reason (Section 7031.5, Business and Additional Sign Branch Circuits o o o o ° OG
'
Professs Code):
I, as owner of the property, will do the work and the
Misc. Conduits&Conductors ° ° 38.50
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , o 0 0 3 8,5 0 0'
Business and Professions Code).
CONSTRUCTION LENDING AGENCY O G 1 688
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
Lender's Name bo
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
&sd7o
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
2na
tives,of thisCounty to enter upon
erty for inspection p7poses.
SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of Permits at
De OO s