HomeMy Public PortalAbout4839ALESSANDRO AVE_Electrical (2) WORKERS'COMPENSATION DECLARATION CE-806 10i81 APPLICATION FOR ELECTRICAL PERMIT {�
I hereby'affirmLthat I have a certificate of consent to self insure, CE-8o6G J
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
cope thereof(Sec. 3800.Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB (�� S�� ✓�-�J�»� ��
El Certified copy is hereby furnished. EACH NO. FEE ADDRESS (,
New Residential Bldgs.& Pools
❑ _ $ LOCALITY
Certified copy is filed with the county building inspection 1 & 2-Family,Sq. Ft. $
department. Multi-family Sq.Ft. NEAREST
CROSS ST. v J
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME E
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
COMPENSATION INSURANCE Outlets:Rec Light t 2 ADDR
First ESS F_
c • �/ v S G
This section need not be completed if the work involved b the Fi20
( p by No. Additional CITY C Tel. No. �JI
permit is for one hundred dollars ($100) or less.) PLAN CHECK
1 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'Compens on Laws. Lighting Fixtures First 20 ADDRESS
Additional
v Total No. CITY Tel.No.
Date Applican " 0 Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APP CANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation •Range—L Heater_ D.W. 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 _ W.H.
LICENSED CONTRACTORS DECLARATION Fan Other_ CITY Tel.No.
'Hood ��
I hereby affirm that I am licensed under provisions of Chapter 9 S V LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. �� REG.NUMBER Class.
Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSED BY
Power Apparatus& Large Appliances
Size& Type HP,KW,KVA,or KVAR o O
License Number Lic.Class Up to 1 Incl. FINAL U
Over 1 to 10 Ind. DATE VALIDATION
�
Contractor Date Over 10 to 50 Incl. U
❑ FINA
I am exempt under Sec. Over 50 to 100 Inc. BY W
Over 100 d
B.&P.C.for this reason Cn
Services, Swbd., MCC & Panelboards , Z
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp. Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
y
'I✓�Q` I,as owner of the property,will do the work and the structure Misc.Conduits & Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ,
and Professions Code).
CONSTRUCTION LENDING AGENCY
1 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
PERMIT ISSUING FEE
Lender's Address
1 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
representatives of this County to enter upon the above-mentioned
prope y_for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE �
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ature of ermlt e D