HomeMy Public PortalAbout5233ALESSANDRO AVE_Electrical (6) WORKER'S COMPE{fJSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
ct 76A63
I hereby affirm,that I?lave a certificate of consent to self insu}e,
or aLAtiYicate 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 Qf 3 J.
PNo. Company FOR APPLICANT TO FILL IN
❑ :
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE ADDRESS
El $ $ LOCALITY
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. _ NEAREST
department. Multi-family Sq.Ft. CROSS ST. 1 V
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. OIRM NAME ` 5'
COMPENSATION INSURANCE
First 20 WAIL
(This section need not be completed if the work involved by the ,
permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS =j Z % L
I certify that in the performance of the work for which this permit CITY . No.
is issued, I shall not employ p y an y person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation Laws, Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with suchPERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT LQ7ZG�
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed-under provisions of Chapter 9 Over 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. >_LICENSE Class.
Over 50 t0 100 InCI. REG.NUMBB ER d
Over 100 DISTRICT NO. P ESSED BY O
License Number Lie.Class r U
Service bd.
wCC&P��1Jelboa s
Contractor Date 4FINAL
0- ndeU r DATE O
V 400-1000 Amp.Under 600 V �� 1 V
❑ I am exempt under Sec. — VALIDATION U-1
Over 1000 Amp.or Over 600 V FINAL IZ
B.&P.C.for this reason — BRANCH CIRCUIT FEES BY CO
Date: 15A,or 20A, 120V,Lighting or Recept. — Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits -1{
El
41 Or More Branch Circuits _ '"j,; _, •'_i
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp. Power Pole&Appurtenances 3 I`L1 .:
HOME OWNER-BUILDER DECLARATION _
hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit `01
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
.E
2�) as
Misc.Conduits&Conductors i� t_K
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) ,
and Professions Code),
CONSTRUCTION LENDING AGENCY I'I=i"."`•_`�__).1
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) ?; A 0"
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
that the 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
for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
e* ACt
�URITTEE DATE