HomeMy Public PortalAbout4815ALESSANDRO AVE_Electrical (5) WORKERS COMPENSATION DECLARATION CE 863 10/81 APPLICATIOPV FOR ELECTRICAL PERMIT
I `hereby affirm that I have a certificate of consent to self CE 8066
insure or a certificate of Workers Compensation Insurance `COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) f
Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
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� Certified copy is filed with the county building inspec I & 2 Family Sq Ft $ $ LOCALITY
—
tion department Multi family Sq Ft NEAREST
Residential Swimming Pools CROSS ST
Date Applicant l OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS (Outlets Rec` b Light�Sw� MAIL `
COMPENSATION INSURANCE / ADDRESS I� V
ZJ
First 20 ,7 �7
(This permit
i need not be completed rf the work revolved by Total No�� Additional CITY L6 C,,/c� TeI No (�
the permrf is for one hundred dollars ($100)or less ) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws LightinglFixtures First 20 ADDRESS -
Total No Additional
CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICANT
Exemption you should become subject to the Workers Range_ Heater_D W —
Compensat,on provisions of the Labor Code you must forth Oven — Dryer — W M _ ADDRESS ��s )
with comply with such provisions or this permit shall be Top _ FAU —W H — } (�
deemed revoked ' CITY46Z1,-,12_.> Tel No
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_ LICEJ
SE OR
I hereby affirm that I am licensed under provisions of Chapter 9
Disp — Room Air Cond REG NNUMBER ` Class do—/
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROCES BY
and Professions Code and my license is in full force and effect �� >
/_.Wy Size &Type HP KW KVA or KVAR O
License Number / Lic Class FINAL V
r Up to 1 Incl
J �L ail Over 1 to 10 Incl I DATE !j� ��Q r�1 VALIDATION �
Contractor /�✓ ^ / Date Over 10 to 50 Incl / U , J V
❑ FINAL
I am exempt under Sec Over 50 to 100 Inc BY W
100 d y
B &P C for this reason Over �
te -'�°^77 1 Services SWbd MCC& Ponelboards
0 200 Amp Under 600 V i
Signature 201 1000 Amp Under 600 V
ElOver 1000 Amp or Over_600 V
Exemption for Reg Mamt Elect g J �
SINGLE FAMILY , Temp Power Pole &Appurtenances
HOME OWNER BUILDER DECLARATION - _ 92 1 67 A
Sign with One Branch Circuit � , �
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and g - �$ ° o o o ° 2
Professions Code) 2 P° 3150
EJ Misc Conduits& Conductors -
I as owner of the property will do the work and the y
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ® �° ° 0,3 1 5 0 66
7044 Business and Professions Code) O �`2 3_8 3
i
CONSTRUCTION LENDING AGENCY\
j 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 t
PERMIT ISSUING FEE _ t
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County
ordinances and State I regulating Electrical wiring and
hereby a nze rep sen)atives of this County to enter upon
th e en pr erty for inspection p rpos s
^ SEE REVERSE FOR EXPLANATORY LANGUAGE �
L
i
gnature of Perm flee Date r