HomeMy Public PortalAbout4848ALESSANDRO AVE_Electrical (3) WORKERS COMPENSATION DECLARATION CE 863 10/81 APPLICATION FOR ELECTRICAL PERMIT
I Fy"reby afC^
firm that I have a certificate of consent to self „�
insure ora certificate of Workers Compensation Insurance- COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) `
Policy No Company a FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
S i _ L C� T
Certified copy is filed with the county building inspec 1 & 2 Family 4 Ft $ $ LOCALITY 6
tion department Multi family S4 Ft CR SSSST
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw_ MAIL
COMPENSATION INSURANCE ADDRESS
First 20
(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 ) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued I shall not employ a person in any manner
so as to become subject to the W er ompensation Laws Lighting Fixtures First 20 ADDRESS
Additional i
Total No CITY Tel No
Date pplica k Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLI ANT If of making this Certificat APPLICANT .
Exemption you should become subject to the Workers Range_ Heater_D W _ r
Compensation provisions of the 1-6bor Code you must forth Oven _ Dryer — W M — ADDRESS (!/� e Q
i
with comply with such provisions or this permit shall be Top — FAU —W H — i
deemed revoked Hood Fan _ OrCITY
Other—
Q 6 Tel No
_
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp — Room Air Cond REG NUMBER _ 2 Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PRO BY
and Professions Code and my license is in full force and effect Power Apparatus& Large Appliances
Size & Type HP KW KVA or KVAR ✓` O
License Nu ' Lic Class C ry Up to 1 Incl FINAL 1.0
Over 1 to 10 Incl DATE _ / cie2
Contractor Date Oad
G VALIDATION O
Over 10 to 50 Incl FIN4(_/ W
I am exempt under Sec Over 50 to 100 Inc BY ; d
B&P C for this n Over 100 Z
nad MCC & Panelboards —
i f �200A Under 600 VIN
Signatur Under 600 V
❑ Over 1000 Amp or Over 600 V
Exemptio r Reg Moint Elect
i
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 Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and
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) ;96027A
CONSTRUCTION LENDING AGENCY -
I.,hereby affirm that there is a construction lending agency for # e o 0 0 0 2
the performance of the work for which this permit is issued PERMIT FEE - (Sub Total) 1 ° - 2 -S50
(Sec 3097 Civ C )
PLAN CHECKING FEE o 0 0 2 5 5 0
Lender s Name 1 126-86
� PERMIT ISSUING FEE � 5
Lender s Address
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 authorize representotiv sof this County to enter upon
the ab endo ed propert for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sig)tWbre of Permittee /Datei
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