HomeMy Public PortalAbout5233ALESSANDRO AVE_Electrical (5) "✓dORKER'S COMPENSATION DECLARATION 28-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby,affirm that I have a certificate of consent to self insure,
or ap ertificate of Worker's Compensation Insurance, or a certified • COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY , J /
❑ $ $Ft
Sq. . —
Certified copy is filed with the county building inspection 1 &2-Family, NEAREST
department. Multi-family Sq. Ft. CROSS ST. Q(A Y�f
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light j Sw. OWNER OR
NAME
COMPENSATION INSURANCE I
First 20 'MAIL
(This section need not be completed if the work involved by the Total NoI ' Additional a :ADDDDRESs
.
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY �,, AA Tel.N.7 40'"o
is issued, I shall not employ any person in any manner so as to
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 PLAN CHECK
1 p 9 � APPLICANT
Total No. Additional
ADDRESS ..
Date ApplicantC 'RESIDENTIAL AP ,
PLIAN �
NOTICE TO APPLICANT: If, after making this Certificate of ESNOT OVER 3 HP. CITY
Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP. Tei.No.
provisions of the Labor Code, you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked.
Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Ove?3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. }
Over 50 to 100 Incl. LICENSE OR Class.
_ REGNUMBER
(!��j "�/r Over 100 REG.
License Numbers Lic.Class DISTRICT NO. P C ED BY O
r Services,Swbd.,MCC&Panelboards cc
�jj �j y � 0 399 AUnder 600 V FINAL PU p
Contractor Date c - Amp. er DATE
400-1000 Amp. Under 600 V
i
❑ I am exempt der Sec. VALIDATION Over 1000 Amp.or Over 600 V FINAL �- y-G LU
B.&P.C.for this reason RANCH CfRt N11 FEES BY D
U)
Date: 15A,or 20A, 120 , hting or Recept. Z
1 To 0 Branch Circuits
Signature 11 T 40 Branch Circuits
F-141 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION --
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit =( ( _>
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
El 1, Conduits&Conductors z �.T=M 's
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ► - n
and Professions Code). - -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the j iH T
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) 2-7 a
Civ.C.)
PLAN CHECKING FEE _.
Lender's Name
PERMIT ISSUING FEE ;:•••-
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE 15,2 q_0
that the abo a information is correct. I agree to comply with all County
ordinance d State laws regulating Electrical wiring,and hereby authorize
represe ves of this County to enter upon the above-mentioned property
for ins n,p rp S. � SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGN TURE OF PEQ EE DATE