HomeMy Public PortalAbout4926ALESSANDRO AVE_Electrical (4) WORKERS'COMPENSATIONDECLARATION APPLICATION FOR ELECTRICAL PERMIT
�, CE-806G (2-80)
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.)
FOR APPLICANT TO FILL IN ADDRESS
D
Policy No. ADDRESS
Company EACH NO. FEE � >JCJs•,
New Residential Bldgs.&Pools
❑ Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ LOCALITY
❑ Multi-family Sq. Ft. NEAREST ^ r�
CertCROSS ST
department. esi
ified copy is filed with the county building inspection
Rdential Swimming Pools �y tel' p*�-
-
FO ROR
RM NAME d (O C' 19e0
Date Applicant Outlets: Rec.—LightMAIL
First 20 �Sw. ADDRESS / E
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY C�i Tel N'o.rCOMPENSATION INSURANCE j
' >
PLAN CHECK 0-
APPLICANT l O
(This section need not be completed if the work involved U
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS
Total No. Additional
I certify that in the performance,of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No. O
permit is issued, I shall not employ any person in any manner PERMIT y U
so as to become subject to the W ers;Co pe sation Laws. Range_ Heater_D.W. APPLICANTDA
/✓ e,AJ. hLC I" d
G Overi _ Dryer_W.M. ADDRESSC Z
Date ^`� Applican Top _ FAU _W.H.._
Hood _ Fan _Other_ CITY �������j Tel No.v c
�I�syQQ
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 Q
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT/NO. C ED BY
with comply with such provisions or this permit shall be Size&Type HP,KW, KVA,or KVAR
deemed revoked.
Up to 1 Incl v " �
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl. DATE ! l
Over 10 to 50 Incl. VALIDATION
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL l<
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY `
ness and Professions.Code, and my license is in full force and it„
effect.
Services ,�
License Number Lic.Class- c < Amp. Under 600 V
y�� / 201-1000 Amp.Under 600 V
Cont racto i44J-/2oD�ataz ��3��� Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits c 0'g 2 2 a
ness and Professions Code): +
Misc.Conduits&Conductors # o 0 0 0.0 2
I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— ,
structure is not intended or offered for sale (Section 2,o 0 1 9.50
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency ° o ° 1 9. 50 c=�
for the performance of the work for which this permit is
issued (Sec. 3097,Civ.C.). PERMIT FEE (Sub-Total) Q a 0 4—8 1
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 the TOTAL FEE
above information is correct.I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby autho iae representatives of this County to enter upon
the above- ent`onedpro ert j inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
919ture of Permittee Date