HomeMy Public PortalAbout4908ALESSANDRO AVE_Electrical (4) WORKERS' COMPENSATION DECLARATION CE-806G
10/81 APPLICATION
ICATION F®® ELECTRICAL PERMIT
I-h�reby affirm that I have a certificate of consent to self insure, CE-9osG !1r 1�` v �Y fl L \.+ fl
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or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is herebyfurnished. EACH NO. FEE ADDRESS
New Residential Bldgs.&Pools
$Ft $
S
il
Famy, q. . _
Certified copy is filed with the county building inspection 1 & 2- LOCALITY
NEAREST
department. Multi-family Sq.Ft.
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME /} ,'S
CERTIFICATE OF EXEMPTION FROM WORKERS' ' MAIL
COMPENSATION INSURANCE Outlets:Rec Light t 2 — ADDRESS ,040 57-
(This section need not be completed if the work involved by the First 20 CITY I.N
permit is for one hundred dollars($100)or less.) Total No. Additional c10VPL e T�
I certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall not employ any person in any manner so as to APPLICANT
become subject to the Workers' mpensation Laws. Lighting Fixtures First 20 ADDRESS
Total No.p Additional CITY Tel.N
Date f7'�� �ee/ Applicant L o _
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ 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.
CITY el.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby. affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE
(commencing with Section 7000) of Division 3 of the Business and
REG.NUMBER
ER Class.
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROCESSE BY
Size& Type HP,KW,KVA,or KVAR J O1
License Number Lic.Class Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE i VALIDATION OO
Contractor Date Over 10 to 50 Incl.
F (�
I am exempt under Sec. Over 50 to 100 Inc. �
B.&P.C. for this reason Over 100 N
Services, Swbd.,MCC& Panelboards l
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
'� ❑
Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V
SINGLE FAMILY Temp.Power Pole& Appurtenances 7
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit i
j I herebyaffirm that I am exempt from the Contractor's License Law q
i for the fol lowing reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits . ACCT v
Code):
` Misc.Conduits & Conductors =72`°50
I,as owner of the property,will do the work and the structuref��
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). t 1 V Y 25 5C)
CONSTRUCTION LENDING AGENCY .�
I hereby affirm that there is a construction lending agency for the '``5
.53
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) 4�ltt7ti8 tJIJ
Civ.C.). °
PLAN CHECKING FEE
f Lender's Name �$ 6/12/89
PERMIT ISSUING FEE �q$�
Lender's Address P 39� X11028
16
I 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
77,Y)'
or inspectio es.
SEE REVERSE FOR EXPLANATORY LANGUAGE
7
{ qi_qoakrre of Perms a Date