HomeMy Public PortalAbout4926ALESSANDRO 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 No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
❑ _ $ $ LOCALITY
Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft.
NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Residential Swimming Pools ASSESSOR
Date Applicant MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rea_� Light Sw. /D OWNER OR FIRM NAME
C�
' COMPENSATION INSURANCE First 20 T
(This section need not be completed if the work involved by the MAIL
permit is for one hundred dollars($100)or less.)
Total No. Additional ADDRESS , 7✓ /� FCJ
I certify that in the performance of the work for which this permit CITY !�'/�f Tel.NoM&6#I
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
�f1 cJl�j"15;1 ✓� / 7- ADDRESS
Date 4O Applicant after
his Ce Liy RESIDENTIAL APPLIANCES NOT OVER 3 HP.
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. �j _ 2
(gommencing with Section 7000) of Division 3 of the Business and CITY ./i!�`' Tel. fJ _
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl.
Over 50 to 100 Incl. LICENSE OR
REGQ /� �7 Class.
Over 100 .NUMBER a
License Number ` � / • Lic.Class DISTRICT NO. PR CC ED BY O
Services,Swbd.,MCC&Panelboards �0� Gir�l�df�Vt�eC'c/
p�/J�F�/, 0-399 Am Under 600 V FINAL Q
ContractorFJ/�d/T/ aWo Date p' DATE
❑ 400-1000 Amp.Under 600 V
I am exempt under Sec. I Over 1000 Amp.or Over 600 V FINAL VALIDATION LlJ
B.&P.C.for this reason BRANCH CIRCUIT FEES BY CD Z
Date: � 15A,or 20A,120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
EJ 41 Or More Branch Circuits
Exempti for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 2
SINGLE FAMILY Temp. Power Pole&Appurtenances ACCT o e
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 3303 37a3;0
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits i T'�'EM�
Code): 1 !1 ITEMS
1 ^�
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors TOTAL 37 o 30
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) .,
and Professions Code). CHECK .37.30
CONSTRUCTION LENDING AGENCY
CHANGE .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) �{�y /�y p
Civ. C.) �D 0000-0001 2/23/ 6
PLAN CHECKING FEE 499 1 A�l10Q04
Lender's Name y
PERMIT ISSUING FEE � ( Q
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
fo 'Inspect 6A purpo s. SEE REVERSE FOR EXPLANATORY LANGUAGE
a.694-4-
IGNATURE OF PERMITTEE DATE