HomeMy Public PortalAbout4821ALESSANDRO AVE_Electrical (3) WORKER S COMPENSATION DECLARATION 20 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT
76A663
o hereby affirfn that I have a certificate of consent to self Insure 76A663
or a certificate of Worker s Compensat+on Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab )
Policy NO/4&,5 ompany � �r C nil FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished New Residential Bldgs &Pools EACH NO FEE �—^
d ❑ i + g $ _ $ LOCALITY
Certified co is fled with the count building Ins ection 1&2 Family Sq Ft {
PY Y 9 P — NEAREST
department Multifamily Sq Ft CROSS ST C
Date �/—73` Appllc t Residential Swimming Pools ASSESSOR -11
MAP BOOK C�z PAGE PARCEL
CERTIFICATE OF E ION FROM WORKERS � OWNER oR
COMPENSATION INSURANCE Outlets Rec Light�rst 20 , y(J FIRM NAME 5
(This section need not be completed if the work Involved by the MAIL L O
permit is for one hundred dollars($100)or less) Total No Additional ADDRESS 7
I certiify that in the performance of the work for which this permit CITY . Tel No, ,,
is Issued I shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws _ Lighting Fixtures First o A PLICANTCHECK
Total No Additional
ADDRESS
Date Applicant 15 OR 20A 120V BRANCH CIRCUITS
NOTICE-TO APPLICANT If after making this Certificate of J! CITY Tel No
Exemption you should become subject to the Workers Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT J
P Y P Y APPLICANT
provisions or this permit shall be deemed revoked ' 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION ADDRESS
a
I herebiy affirm that I am licensed under provisions of Chapter 9 15 OR 20A 208V TO 277V LIGHTING EACH
(commencing with Section 7000) of Division 3 of the Business and _ CITY Tel No0
Professions Code and my license is in full force and effect RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR
C,f (/(�) Power Apparatus&Large Appliances _ REG NUMBER Class 0
License Number- /�� Lic Class ^� Size&Type HP KW KVA or KVAR DISTRICT NO PR E D BY O
_ p U
Up to 3 Incl O W
�1 ,L„ __ .�. �rJrY7h f�
Ove r3t0101nC1 FINAL CD
cl
ContractytrlJl7r �(�✓l V_ A7ate DATE / Z
FINAL
Over 10 to 50 In _
I am exempt under Sec Over 50 to 100 Incl VALIDATION Z
B&P C for this reason Over 100
BY
L_ Services Swbd MCC&Panelboards
0 200 Amp Under 600 V
Signatui 201 1000 Amp Under 600V
El
Over 1000 Amp or Over 600 V
Exption for Reg Maint Elect
SINGLE FAMILY Temp Power Pole&AppurtenancesI
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractors License Law 11FF»
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits
Code)
❑ I as owner of the property will do the work and the structure Misc Conduits&Conductors T /�
Is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) ® (/
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 (Sec 3097 PERMIT FEE ;. (Sub Total) _
Civ C)
PLAN CHECKING FEE
Lender s Name �7
PERMIT ISSUING FEE GY� 76
Lender s Address I
I certify that I have read this application and state that the above TOTAL FEE /a pt 6
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 ti
z
SIGNATURE OF APPLICANT OR AGENT DATE ` e