HomeMy Public PortalAbout4809ALESSANDRO AVE_Electrical (3) ( /✓ORKERS COMPENSATION DECLARATION 720 00196A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O
11hereb at�irm that I have a certificate of consent to self CE 80066G
inure or x3c6rtificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or a certified copy thereof (Se, 13800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
❑Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ — $ LOCALITY
tion department Multi family Sq Ft NEAREST
Residential Swimming Pools CROSS ST
Date Applicant OWNER OR
FIRM NAME YU
CERTIFICATE OF EXEMPTION FROM WORKERSOutlets RecLi ti MAIL
COMPENSATION INSURANCE ght Sw * 4 ADDRESS O A DC_
First'2d 1 �/`/
(This section need not be completed if the work involved by Total No Additional` CITY Q ( Tel No '7"T _ 7�
the permit is for one hundred dollars (;100)or less )
i PLAN CHECK
I certify that',n 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 Compenso n Laws Lighting Fixtures First 20 ADDRESS
Additional
Date _ — Applicant Total No CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
J
Exemption you should become subject to the Workers Range— Heater—D W — APPLICATION 7R��' �(J
Compensation provisions of the Labor Code you,must forth Oven — Dryer —W M — ADDRESS v(JLT D v
with comply with such provisionsror this permit shall be Top — FAU —W H —
deemed revoked Hood — Fan —Other_ CITY,5J' 4,8R1&(_Tel No 3p _ SCS
LICENSED CONTRACTORS DECLARATION Dis — Room Air Cond — LICENSE OR
I%hereby affirm that I am licensed under provisions of Chapter 9 p REG NUMBER 5-1 '%'90"7Class C--1/0
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROC ED BY
and Professions Code and my license is in full force and effect t //�/ d
L-L7 / Size 8 Type HP KW KVA or KVAR J�(/d 0
License Number/�I Lic Class D Up to 1 Incl FINAL 0
Over 1 to 10 Incl DATE V (DATION
Contractor eDate
❑ Over 10 to 50 Incl l—
FINAL U
I am exempt under Sec Over 50 to 100 Inc BY LU
B 8P C for this reason Over 100 0 6,�0 A
D Services Swbd MCC& Panelboards # o • o o e 2 Z
0 0 200 Amp Under 600 V
Signature - ��� 201 1000 Amp Under 600 V M r( e s 2 5 5_0
❑ O\,er 1000 Amp or Over 600 V J Exemption for Reg Maint Elect o s e 2S 5 0 X0
SINGLE FAMILY Temp Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from tRe Contractor s License Sign with One Branch Circuit 09,09- 88
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits
Professions Code) J
❑ I as owner of the property will do the work and the Misc Conduits&Conductors
structure is not intended or offered for sale(Section 7044 Other (See Complete Fee Schedule)_ ,
Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
i�1
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 roperty for inspection purposes - SEE REVERSE FOR EXPLANATORY LANGUAGE
�Sigg azure of Permittee Date '�