HomeMy Public PortalAbout4848ALESSANDRO AVE_Electrical (2) WORKERS COMPENSATION tateDECLARATION
corse CE 863 10/81 APPLICATION FOR ELECTRICAL PERMIT
G-f1RRrm that I have a certificate of consent to self CE 8066
inure o� a certifitate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB L
Certified copy is hereby furnished 'New Residential Bldgs & Pools EACH NO FEE ADDRESS ,
❑ li& 2 Family S Ft $ — $ LOCALITY
Certified copy is filed with the county building inspec Y 4
tion department Multi family Sq Ft — NEAREST nn ^
Residential Swimming Pools CROSS ST w /y —914
Date Applicant OWNER OR
FIRM NAME ,-
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec�Light1LSw MAIL
COMPENSATION INSURANCE First 20 d ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITY Tel No
the permit is for one hundred dollars ($100)or less )
I certify that in the performance of the work for which this PLAN CHECK
r i
permit is issued I shall not employ any person in any manner y
so as to become subject to the W e Compensatio Laws Lighting Fixtures ) First 20 ADDRESS
_ Total No Additional
Date � pplicant - - CITY Tel No
NOTICE TO APPLICANT If after making—This Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the Workers Range_ Heater_D W _ APPLICANT
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M — ADDRESS_q
with comply with such provisions or this permit shall be Top — FAU —W H —
deemed revoked CITY -
Tel No
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
Disp — Room Air Cond LICE EOR Class If �(J
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER G
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCESSED BY
and Professions Code and my license is in full force and effect Power Apparatus& Large Appliances _
QSize &Type HP KW KVA or KVAR O
License Number 9�
�7 X 2) Lic Class Ilf- y Up to 1 Incl FINAL V
ContractorA2 ate Over 1 to 10 Incl DATE _-� VALID ION O
❑ Over 10 to 50 Incl FINA U
I am exempt under Sec Over 50 to 100 Inc BY
B &P C for this reason Over 100 H
Date
Services Swbd MCC& Panelboards , Z
0 200 Amp Under 600 V OR
Signature 201 1000 Amp Under 600 V 6 9 8 A
F] Exemption
1000 Amp or Over 600 V # s - o - o 2
Exemption for Reg Marnt Eject
SINGLE FAMILY Temp Power Pole &Appurtenances } - - 3 1 5 0
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit o 0 0 3 1 5 0 v
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 0505-87
Professions Code)
❑ I as owner of the property will do the work and the Misc Conduits&Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)-
7044 Business 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 PERMIT FEE (Sub Total) 0 -
(Sec 3097 Civ C )
PLAN CHECKING FEE�
Lender s Name
Lenders Address
PERMIT ISSUING FEE
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 laws regulating Electrical wiring and ,
hereby±thor,ze representatives of this County to enter upon
the e coned prop rty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date