HomeMy Public PortalAbout5233ALESSANDRO AVE_Electrical (4) r
)WORKERS COMPENSATION DECLARATION 63
� ' f CE APPLICATION FOR ELECTRICA i RMIT
CE 8 806G (2 80)
I hereby-affirm that I have a certificate of consent to self ( COUNTY OF LOS ANGELESING AND SAFETY "
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C) I l
FOR APPLICANT TO FILL 1 JOB ��
Policy No �es
Company EACH NO EE ADDRESS
I New Residential Bldgs &Pools
Certified copy is hereby furnished 1 &2 Family Sq Ft $ $ LOCALITY
NEAREST
Certified copy is filed with the county building inspection Multi family wi Ft CROSS ST L�
department ( Residential SwimmingrPoois OWNER OR �� �,4e
FIRM NAME
Date Applicant Outlets Rec I Light 4 SwAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS Total No\ Additional CITY Tel No 2 s 3Y3 }
COMPENSATION INSURANCE PLAN CHECK tl
(This section need not be completed if the work involved ( APPLICANT OV
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS
Total No Additional irO
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No
permit is issued-I shall not employ any person in any manner PERlMtT W
so as to become subject to the Workers Compensa�L / Range_ Heater D W + APPLICANT
Oven Dryer_'W M ADDRESS ��� Z
��
Date S plican Top _ FAU W H _
Hood Fan Other_ - CITY u� C Tel No Ca
NOTICE TO APPLICANT If after making this Certificate of Disp Room Air Cond_ �� LICENSE Offlil
Exemption you should become subject to the Workers ) REG NUMBER 2 Class
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO P E BY
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP KW KVA or KVAR
Up to 1 Incl
Over 1 to 10 Incl FINALDATE
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl Z � v � ` VALIDAT N
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
License Number�� Lic Class 201 200 Amp Under 600 V
L
1 1000 Amp Under 600 V i
Contractor Date_ 1�^ Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit
Additional Sign Branch Circuits
License Law for the following reason (Section 7031 5 Busi
ness and Professions Code)
Misc Conduits&Conductors
❑ I as owner of the property will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044 Business and Professions Code) 1
CONSTRUCTION LENDING AGENCY _
I hereby affirm that there is a construction lending agency 3 4 5 7 A
for the performance of the work for which this permit is PERMIT FEE (Sub Total) i
issued(Sec 3097 Civ C)
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) # o o 0 0 0 2
l
Lender s Address PERMIT ISSUING FEE L o o Q
o 0 0 � 1006
\
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 12 1 8_8 0
ordinances and State laws regulating Electrical wiring and
thor'
r'ze represent tives ounty to enter upon
the ove ntloned proper y urposes 1 '
SEE REVERSE FOR EXPLANATORY LANGUAGE �
0 4 i
Signature of permittee Date