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HomeMy Public PortalAbout4902ALESSANDRO AVE_Electrical (6) WORKERS COMPENSATION DECLARATION 63 CE806G (2 80) APPLICATION FOR ELECTRICAL PERMIT CE 8 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure or a certificate of Workers Compensation Insurance or, a certified copy thereof(Sec 3800 Lab C) Policy No Company , FOR APPLICANT TO FILL IN New Residential Bldgs &Pools EACH NO FEE ADDRESS Certified copy is hereby furnished "1 &2 Family Sq Ft $ — $ LOCALITY ,) Multi family Sq Ft — NEAREST Certified copy is filed with the county building inspection CROSS ST department Residential Swimming Pools OWNER OR // FIRM NAMEOA-71(, ( or /J I Date Applicant Outlets Rec-Light_ Sw (' i © ADDRESS 7 �� First 20 CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY ' Tel No ;Zr-?Z Z COMPENSATION INSURANCE } � PLAN CHECKCL (This section need not be completed if the work involved APPLICANT O Lighting Fixtures First by the permit is N for one hundred dollars ($100) or less) Total No Additional cc ADDRESS U onal I certify that in the performance of the work for which thisFixed Appliances Not Over 1 HP CITY Tel No 0 permit is issued I shall not employ any person in any manner PERMIT () so as to become subject to the Workers Compensation Laws Range_ Heater_DW APPLICANT W Oven Dryer_W M ADDRESS to Date Applicant Top FAU _W H f Z Hood Fan _Other_ CITY Tel No NOTICE TO APPLICANT If after making this Certificate of Disp — Room Air Cond_ LICENSE OR Exemption you should become subject to the Workers REG NUMBER Class Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT PROCESSEp BY with comply with such provisions or this permit shall be deemed revoked Size&Type HP KW KVA or KVAR Up to 1 Incl FINAL Over 1 to 10 Incl DATE _,rrte� LICENSED CONTRACTORS DECLARATION - Over 10 to 50 Incl fir✓ VALIDATION I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINALB1, 9 (commencing with Section 7000) of Division 3 of the Busi Over 100 r --+�••�•��— ness and Professions Code and my license is in full force and effect Services License Number Lic Class 0 200 Amp Under 600 V 201 1000 Amp Under 600 V Contractor Date Over 1000 Amp or Over 600 V HOME OWNER BUILDER DECLARATION Temp Power Pole& Appurtenances I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits iib 0 6 A ness and Professions Code) ��,(' Misc Conduits& Conductors # 0 0 0;0 0 2 dill I as owner of the property will do the work and the Ileee Complete F e Sched le)— structure is not intended or offered for sale (Section 2 ° ° 1,030 7044 Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency 0'0 ° 1 0 3 0 0 for the performance of the work for which this permit is PERMIT FEE (Sub Total) issued(Sec 3097 Civ C) 0903-82 Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) Lender s Address PERMIT ISSUING FEE I certify that I have read this application and state that tjie TOTAL FEE D above information is&rtor omply with all County ordinances and StaElectrical wiring and 6 hereb uthorize reCounty to enter pon the o e mentionedtion purp es Z SEE REVERSE FOR EXPLANATORY LANGUAGE ignature of Permittee Da e i