HomeMy Public PortalAbout4908ALESSANDRO AVE_Electrical (3) WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab.C.)
Policy Mo. Company FOR APPLICANT TO FILL IN JOB
ADDRESS o A,Ii� �� 7
Certified copy is hereby furnished. New Residential Bld &Pools NO. EACH FEE
❑ engs. — $ $ LOCALITY-��P(� G j.r-� (2A .
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft.
department. Multi-family S Ft. NEAREST
P Y q CROSS ST. SR
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK �Q PAGE 2 PARCEL
• CERTIFICATE OF EXEMPTION FROM WORKERS' / SW OWNER OR
COMPENSATION INSURANCE Outlets:Rec Light First 20 V�D FIRM NAME 0 S �RQ_C>_rT_A "$k,
(This section need not be completed if the work involved by the _J MAIL tfg Fes. ,4,JD ST—
Ipermit is for one hundred dollars($100)or less.) Total No. / Additional O ADDRESS �
I certify that in the performance of the work for which this permit CITYTel.No.
is issued, I shall not employ any person in any manner so as toT"� ��^�
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 / APPLICANT CHECK
Total No. Additional
ADDRESS
IT
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP .5Z7.5Z7.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
LICENSE OR
Over 50 t0 100 Incl. Class.
REG.NUMBER la
License Number Lic.Class
Over 100 - DISTRICT NO. PROCESSED BY O
r� V
Services,Swbd.,MCC&Panelboardsv�
Contractor Date 0-399 Amp.Under 600 V
INAL
EJ
DATE
400-1000 Amp.Under 600 V * ~
I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL �_ ' VALIDATION )U
B:&P.C.for this reason BRANCH CIRCUIT FEES BY U)
Date: 15A,or-20A 12
igg r pt Z
ranc Ir ISignature 1 40 Branch Circ s
EJ41 Or More Branch Circuits ?
Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances AM AMA!
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 3,307
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
tc
I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 1343, - 45
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) -r-- :ttrr i� e
and Professions Code). CHH •t'= 1 1 °415
CONSTRUCTION LENDING AGENCY "'HIANIGE .00
I 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) f
Civ. C.) _0000-6001 _I: }!':�L
PLAN CHECKING FEE
Lender's Name 95714!0! AN 7 2-51-:'!
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above 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 property
for In ti purpo as. SEE REVERSE FOR EXPLANATORY LANGUAGE
SI TURE ERMITTEE DATE