HomeMy Public PortalAbout6042 ALESSANDRO AVE_Electrical__ I WORKERS COMPENSATION DECLARATION CE806G (280) APPLICATION FOR EL.ECTRICAL PERMM '
y
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES r � BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or
a cert ed copy� thereof a 3800 Lab C)33f /`� / �/�C FOR APPLICANT TO FILL IN JOB
Policy No Company 54'iL Q �/ EACH NO FEE ADDRESS Q '#'�o1n
0
❑ New Residential Blldgs &Pools
Certified copy is hereby furnished 1 &2 Family Sq Ft $ $ LOCALITY �h �'e
4® Multi family Sq Ft — NEAREST
Certified copy is filed with a county building msp ction CROSS ST
Residential Swimming Pools
departmenpptaXFO RM NA E ll(� k ek ,Q6/
Datel -) `aApWNER OR
plicant Outlets Rec_Light Sw MAIL
First 20 ADDRESS 2 .4.�b
CERTIFICATE, F EXE 4vI TION FROM WORKERS Totail No Additional CITY / Tel No gZ3 1.
COMPENSATION INSURANCE t - PLAN CHE r d
(This section need not be (Work
d if the work involved
APPLICANT
by the permit is for one dollars ($100) or less) Lighting Fixtures First 20 ADDRESS J
i Total No Additional ccO
I certify that m the performthe work for which this 1 Fixed Appliances Not Over 1 HP CITY Tel .
permit is issued i shall not any person in any manner t PERMIT C W
so as to become subject to ters Compensation Laws Range_ Heater_D W f APPLICANT 6c�rL i i�L ItiJfyl a
I Oven Dryer!W M
r ADDRESS �D "Cit �� �(�� Z
Date Applicant Top FAU W H _ ,(A
Hood Fan _Other_ r CITY rr �/ Tel No 6
NOTICE TO APPLICANT If after making this Certificate of Disp Room Air Cond_ LICEN E OR /
Exemption you should be ome subject to the Workers REG NUMBER' F615 Class d—C3
Compensation provisions of he Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PR CES ED BY
with comply with such provisions or this permit shal0be
deemed revoked Size&Type HP KW KVA or KVAR
/ Up to 1 Incl 11�0 J I
FINAL U
Over 1 to(&Inccl DATE VALIDAT N
- LICENSED CONTRACTORS DECLARATION 1 Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100'lnc BY AL
9 (commencing with Section 7000) of Division 3 of the Busi Over 100 '
ness and Professions Code and my license is in full iforce and
effect Services J,—,(paA
*ontractor—
nse Nu bei u L c Class �r� 0 200 Amp Under 600V V
T� — 201 1000 Amp Under 600 V
r
Date '/.t�rt`j'� d Over 1000 Amp or Over 600 V
HOME Orintended
ILDER DECLARATION _ Temp Power Pole&,Appurtenances ,
I hereby affirm am exempt from the Contractors Sign with One Branch Circuit t
License Law for towmg reason (Section 7031 5 Busi Additional Sign Branch Circuits _ )
ness and Professio )
Misc Conduits& Conductors i e
i as owner property will do the work and the Other (See Complete Fee Schedule)—
is
ended or offered for sale (Section7044 Businerofessions Code)
CONSION LENDING AGENCY 3'5 4,8 A
I hereby affirm tre is a construction lending agency
for the performathe work for which this permit is PERMIT FEE (Sub Total) # 0 0 0 0 0 2
issued (Sec 3097
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) 2 -,o 2i9 5 0
Lender s AddrPERMIT ISSUING FEE ° ° ° 2 9 5 0 5
1
I certify that//have read this application and state that theTOTAL FEE 2 2 9
—80
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 ab a en ti fined property for inspection purposes SEE REVERSE FORIEXPLANATORY LANGUAGE
s. .t9
nature of Permittee Date j
i
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