HomeMy Public PortalAbout5233ALESSANDRO AVE_Electrical (3) WORKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab.C.)
FOR APPLICANT TO FILL IN SOB
Policy No. Company EACH NO. FEE ADDRESS
New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY
❑ Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department. Residential Swimming Pools OWNER OR
FIRM NAME
Date Applicant Outlets: Rec,;�fLight Sw. AIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY Te }
COMPENSATION INSURANCE
PLAN CHECK a
APPLICANT
(This section need not be completed if the work involved U
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS
Additional cc
Total No. Q
I certify that in the performance of the work for which thisCITY Tel No. F-
Fixed Appliances Not Over 1 HP
permit is issued, I shall not employ any person in any manner PERMIT W
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT CL
Oven _ Dryer_W.M. ADDRESS U)
Date Applicant Top _ FAU _W.H.._
Hood _ Fan _Other_ CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. — Room Air Cond.— LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE ED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP,KW, KVA,or KVAR
Up to 1 Incl. r FINAL
�. sy
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE 0� ��� k VALIDATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY
ness and Professions.Code, and my license is in full force and
effect. Services
0-200 Amp. Under 600 V
License Number Lic.Class
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole& Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit 6 3 2 7.A
Sign Branch Circuits
License Law for the following reason (Section 7031.5, Busi- o 0 0 o 0.2
ness and Professions Code):
Misc.Conduits& Conductors
I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— 2.10 0 2 1,7 0
structure is not intended or offered for sale (Section o 0 o 2 1,7 0 cii
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 0 9.2 0�—8 2
for the performance of the work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.).
Lender's Name
PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
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 laws regulating Electrical wiring, and ��
hereby authorize representatives of this County to enter upon
the above-mentioned property tor'inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Si natur of Permittee Date