HomeMy Public PortalAbout4803ALESSANDRO AVE_Electrical (4) WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3880000 Lab.. C.)
Policy No.��/',`Company 5141,? `06' FOR APPLICANT TO FILL IN JOB
ADDRESS y,�{'� hw
❑ . SQA /f7
Certified copy is hEveby furnished. New Residential Bldgs.&Pools NO. EACH FEE
❑ _ $ $ LOCALITY a�jm
Certified copy Is filed with the count buildin eefien—_ 1 &2-Family,Sq.Ft.
department. y Multi-family Sq.Ft. CROSS ST.
Date X1157 A ant - Residential Swimming Pools MAPBOOKPAGE PARCEL
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CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR %
COMPENSATION INSURANCE Outlets:Rec.—Light Sw. , Po + FIRM NAME [�
First 20 MAIL rj�`� �• , ^ !'
(This section need not be completed 0 the work involved by the Total No. Additional ADDRES /, ? (�( All /,
permit is for one hundred dollars($100)or less.) J/
I certify that in the performance of the work for which this permit CITY y.ll� Te Ls
s!� -
is issued, I shall not employ any person in any manner so as to PL N CHECK
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 A LICANT
Total No. Additional
.�' ^ DDRESS
Date Applicant rHER
IAL A PLIA S N T R3H �'�� � oNOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption, you should become subject to the Workers' Compensation OAPPLIANCES NOT OVER 3 HP.
provisions of the Labor Code,.you must forthwith comply with such ZADDRESS RMIT
P y Power Apparatus&Large Appliances PLICANT
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR
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 TY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
ENSE B q J/j Class.
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Over 50 t0 100 Incl. .NUMBER / / `7 �'�`'—
/� Over 100 Q.
License Number S��✓ .� Lic.Class� � DISTRICT NO. PR ED BY Q
Services,Swbd.,MCC&Panelboards � IZ
Contracto4�_F Date �/ D P q3 0-399 Amp.Under 600 V DATE O
❑ 400-1000 Amp.Under 600 V `(y
I am exempt under Sec. / VALIDATION 0
Over 1000 Amp.or Over 600 V FINAL LU
B.&P.C.for this reason BRANCH CIRCUIT FEES BYCD
ate: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signatu 5'
I 1 To 40 Branch Circuits
❑ 41 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 ACV.'
Jt
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit AC r cv
for the fallowing reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
6i;' s oma•.
Code): k!
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 ITE t53
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) r 1 TF 98 . 25
and Professions Code). �� r ..
°_•HEE_K 722oy.S
CONSTRUCTION LENDING AGENCY L!s"�,
I hereby affirm that there is a construction lending agency for the b CHANGE =or."
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) jp ,
Civ. C.)
o i rumor`�ini� �'y''}�'f �'}i'� (';
er"er.•e,-rcrn�,..�3-FEt fJ1 00-1_00 f 5£10/94
Lender's Name S •� 22 J ��yt o a
PERMIT ISSUING FEE J t i -I" .-I r,
Lender's Address p`
I certify that I have read this application and under penalty of purlury 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 C o enter upon the above-mentioned property
for ins ec' rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF PERMITTEE DATE