HomeMy Public PortalAbout5233ALESSANDRO AVE_Electrical (7) r
WORKERS COMPENSATION DECLARATION CE 863 10/81 APPLICATION FOR ELECTRICAL PERMIT
reby affirm that I have a certificate of consent to self CE 806E _
1 s e or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY�G
o certified copy thereof (Sec 3800 Lob
/C�/►)(� y`� �,/ * ' '
olicy No l?" Company �t(K,A%� FOR APPLICANT TO FILL IN 1 JOBADDRESS �C�fI�LAM
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
1 &2 Family S Ft $ — $ LOCALITY --��`
Certified copy is filed with t e ty build mspec i Y q
tion department Multi family Sq NEAREST Ft
DCRO ST �oq
Residential Swimming Pools WN R
ate App icant
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec�Ltght Sw MAIL '
COMPENSATION INSURANCE First 20 ADDRESS Z U
(This section need not be completed if the work involved by Total No CITY Tel o
the permit is for one hundred dollars ($100)or less ) Additional \ z
PLAN CHECK
I certify that in The performance of the work for which this APPLICANT
permit 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 ADDRESS
1 Total No Additional
CITY Tel No
Date ApplicanT Fixed Appliances Not Over 1 HP PERMIT �—
NOTICE TO APPLICANT If after making this Certificate of APPLICANT
Exemption you should become subject to the Workers Range_ Heater_D W — `
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M — ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W H —
deemed revoked Hood _ Fan _Other— CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENS OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROCESSED Y
and Professions Code and my license is in full force and effect 0
Size& Type HP KW KVA or KVAR
License Number s—�� k Lic Class��� Up to 1 Incl FINAL V
11yyi �� Over 1 to 10 Incl DATE _ n VALIDATION
Contractor� lw � Date Over 10 to 50 Incl `FO
FINAL
I am exempt under Sec Over 50 to 100 Inc BY ` LYS
Over 100
B 8P C for this reason y
► �� �� Z
Date Services Swbd MCC 8 Panelboards
0 200 Amp Under 600 V Tu
Signature 201 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect
SINGLE FAMILY / Temp Power Pole& Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits ;?971L 1 A
Law for the following reason (Section 7031 5 Business and
Professions Code) # o o o o o 2
Misc Conduits& Conductors 4
I as owner of the property will do the work and the 2 0 0'� 2 ']5
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ►
7044 Business and Professions Code) o 0 0 1 2 7 5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for 03 1 5'—8 4
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) Z J
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE _ (Q
Lender dress I
` I ce f tho I have read this application and state that the TOTAL FEE
abo i form tion is correct I agree to comply with all County
ordi s a d St jaws regulating Electrical wiring and
I
th ize �p esentatives of this County to enter upon
th e i d property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date