HomeMy Public PortalAbout4832ALESSANDRO AVE_Electrical (4) f
WORKERS COMPENSATION DECLARATION CEA8663 o6G 10i81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure , !
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C) , +
+. I FOR APPLICANT TO FILL IN JOB
Policy No - Company _ ,
Certified copy is hereby furnished New Residential Bldgs & Pools ' EACH s NO FEE ADDRESS
Certified copy is filed with the county building inspection
1 & 2 Family Sq Ft $ — $ LOCALITY,,
v � r department Multi family Sq Ft NEARESTCROSS ST LO Gam!
Residential Swimming Pools OWNER OR
Y h iDate Applicant # H S y t FIRM NAME RS�
Outlets Rec
j + CERTIFICATE OF EXEMPTION FROM,WORKERS fes- Llgh� w� M MAGIL 0y �
n COMPENSATION INSURANCE ' ti`s ,� , , ADDRESS 0 Z A 4 A b 9
First 20
(This section need not be completed rf the work involved by the Total No Additional CITY 2 ` T Tel No �
permit Is for one hundred dollars($,100)or less) PLAN CHECK
I certify that in the,performance of the work for which this permit APPLICANT
is issued I shall not employ any person in any manner so as to
become subject to the Workers` Compensation Laws Lighting Fixtures First 20 ADDRESS
7 Additional
Total No - CITY Tel No 9
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of
Exemption 4you should become subject to the Workers Compensation Range_ Heater_ DW ` } APPLICANT
provisions of the Labor Code you must forthwith comply with such Oven Dryer _ W M ADDRESS
provisions or this permit shall be deemed revoked Top FAU _ WH
LICENSED CONTRACTORS DECLARATIONCITY Tel No
Hood Fan Other_
I hereby affirm that I am licensed`under provisions of Chapter 9 LICENSE OR
Disp Room Air Cond ,_ Class
(commenting with Section 7000) of Division 3 of the Business and REG NUMBER
Professions Code and my license is in full force and effect DISTRIC NO PROC SS BY
Power Apparatus& Large Appliances
Size& Type HP KW KVA or KVAR 0
License Number Lic ClassUp U
Over
1 Incl FINAL J /r(J
Ov1 to 10 Incl DATE (� `/� VALIDATION
O 0
Contractor Date Over 10 to 50 Incl U
E] FINAL
I am exempt under Sec Over 50 to 100 Inc BY I 1.1
Q.
Over 100 B&PC for this reason s ()
Date
Services Swbd MCC& Panelboards Z
-+ "' �
0 200 Amp Under 600 V
" Signature 201_ 1000 Amp Under 600 V -
Over 1000 Amp or Over 600 V _
� Exemption for Reg Mamt Elect �
SINGLE FAMILY a s, f Temp Power+Pole& AppurtenancesJL
HOME OWNER BUILDER DECLARATION f + Sign with One Branch Circuit ACICTA
I hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuits ` �'�t1�f 1�a!J
for the following reason (Section 7031 5 Business and Professions x x cw _ 330( �
Code) - 6 1 ITEM
+ Misc Conduits& Conductors j s
I as owner of the property will do the work and the structure
is not intended or offe""red for sale (Section 7044 Business Other (See Complete Fee Schedule) - TOTAL AL 18•
s and Professions Code) + ®T ` MICK 18.75
CONSTRUCTION LENDING AGENCY ��Uy� e�l
Ithereby affirm that there is a construction lending agency for the " 4RrU
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total)
Civ C) + Af���t�t `
PLAN CHECKING FEE r. d, 001gr-0001 10/24/89
Lenders Name
Lenders Address PERMIT ISSUING FEE y 6+67 1 AM7'" l
+
I certify that I have read this application and state that the above TOTAL FEE
information is correct I agree to comply with all County ordinances
and State laws regulating Electrical wiring and hereby authorize u
representatives of this County to entef upon the above mentioned /nt s
property for nspec oses /gEVERSE FOR EXPLANATORY LANGUAGE _ k�
t d
Signat e of Permit Date