HomeMy Public PortalAbout4826ALESSANDRO AVE_Electrical (4) WORKER S COMPENSATION DECLARATION 200019 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 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS
❑ Certified co s hereby furnished NO EACH FEE LOCALITY
PY y New Residential Bldgs &Pools
❑ 1 &2 Family Sq Ft — $ $
Certified copy is filed with the county building Inspection _ NEAREST
department Multifamily Sq Ft CROSS ST
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
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CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec _Light Sw FNAME
OWNER IRM
COMPENSATION INSURANCE P � �7
First 20 MAIL
(This section need not be completed if the work involved by the Total No Additional ADDREss 0 2 ��
permit is for one hundred dollars($100)or less) y
I certify that in the performance of the work for which this permit CITY rZ,/�
is issued I shall not employ any person in any manner so as toPLAN K
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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
provisions or this permit shall be deemed revoked
Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS
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 CITY Tel No
Professions Code and my license is in full force and effect Over 10 to 50 Incl
Over 50 to 100 Incl LICENSE OR Class
REG NUMBER d
License Number Lic Class 1747, Over 100 DISTRICT NO P C SSED BY Q
Ser N1CP,� PPaingl ards ^ O O
Contractor Date O'/8099/l C UfSder 600 V (� FINAL DATE
❑ 4400 1000 Amp Under 600 V ~
I am exempt under Sec VALIDATION U
Over 1000 Amp or Over 600 V FINSLI
B&P C for this reason BRANCH CIRCUIT FEES BY
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Date 15A or 20A 120V Lighting or Recept Z
Signature 1 To 10 Branch Circuits r
11 To 40 Branch Circuits 1 GC Al C T e g
El 41 Li More Branch Circuits ,x303 1 c n 6n
Exemption for Reg Maint Elect 15A 20A 208V To 277V Lighting Br Circuits � 7..77 it O V
SINGLE FAMILY Temp Power Pole&Appurtenances 1 ITEMS
HOME OWNER BUILDER DECLARATION 1 I�
I hereby affirm that I am exempt from the Contractors License Law Sign with One Branch Circuit U` TCITAL � ® �
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits
Code) GiECK 69.60
I as owner of the property will do the work and the structure Mlsc Conduits&Conductors CHANGE 00
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) ® CHANGE IVG
and Professions Code) ��y �1
CONSTRUCTION LENDING AGENCY 0000'0001 3/18/96
1 hereby affirm that there is a construction lending agency for the C
performance of the work for which this permit is issued (Sec 3097 PERMIT FEE (Sub Total) 1 AN I 7°u
O4
CIV C)
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE p
that the above information is correct I agree to comply with all County
ordinanc and State laws regu Elec rical wire g and hereby authorize
repr ent Iv of ou toe to on the ove mentioned property
foi ct o SEE REVERSE FOR EXPLANATORY LANGUAGE
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3 �- o
SIGNATURE OF PERMITTEE DATE