HomeMy Public PortalAbout4803ALESSANDRO AVE_Electrical (5) WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12.91) APPLICATION FOR ELECTRICAL PERMIT
I,hereby affirm that I have a certificate of consent to se76A663 lf insure, '
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.3800 Lab. C.)
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Policy No. `p �� Compan �—�`V` FOR APPLICANT TO FILL IN JOB ® /
ADDRESS
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Certified copy is hereby furnished. New Residential Bidgs.&Pools NO. EACH FEE
❑ _ $ $ LOCALITY
Certified co s filed with the count buildin stia 1&2-Family,Sq.Ft.
copy Y 1>�e NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date
w 1W Appf t ���'� Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. p OWNER OR
COMPENSATION INSURANCE O U FIRM NAME
First 20 h
(This section need not be completed if the work involved by the MAIL
ADDRESS (�L7
permit is for one hundred dollars($100)or less.) Total No. Additional �r
I certify that in the performance of the work for which this permit CITY / �(( Tel.N /}�
is issued, I shall not employ any person in any manner so as to PLAN CHECK t�
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 such PERMIT
Power Apparatus&Large Appliances APPLICANT
provisions or this permit shall be deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS/7
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1 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 CITYL,_ Q0,V'S Tel. t'O
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR n
Over 50 to 100 Incl. REG.NUMBE L ( G-/—y, IJ Class.�^ - s,� 0••'
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[ �r Over 100 DISTRICT NO. PROCESSED BY 0
License Number 9� Lia Class y�
Services,Swbd.,MCC&Panelboards
Contractor — Date 0-399 Amp, Under 600 V FINAE
❑ 1 am exempt under Sec. 400-1000 Amp. Under 600 V
I VALIDATION V
Over 1000 Amp.or Over 600 V FINAL d
B.&P.C.for this reasonBRANCH CIRCUIT FEES BY
Date: 15A,or 20A, 120V,Lighting or Recept. Z_
/ 1 To 10 Branch Circuits
Signature 11 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 o S
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit Fi_l• nS
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 0—,r
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Code):
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I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors. ITEMS
is not intended or offered for sale (Section 7044, @usiness Other(See Complete Fee Schedule) "9I'H( —�A 3 �"re
and Professions Code).
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CONSTRUCTION LENDING AGENCY !_. [
I herebyaffirm that there is a construction lending agency for the C A IGG 0
9 9 Y r`il'l=+ a
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) 15—
Civ. C.)
PLAN CHECKING FEE f-;; C+�
Lender's Name ;� A s_
PERMIT ISSUING FEE ' ',;59A
5 1 IM, io
1e
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
SIGNATURE OF PERMITTEE DATE