HomeMy Public PortalAbout4941ALESSANDRO AVE_Electrical (6) x e -- WORKERS COMPENSATION DECLARATION 63 10/81 APPLICATION FOR ELECTRICAL PERMIT
sC CE 8
I hereby affirm that I have a certificate of consent to self CE 806G
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
p;S, c rtiftea copy thereof (Sec-3880 'T
000/ Lab C ) `�.,n
Pollcy l U1 CompariMAi4NT IS FOR APPLICANT TO FILL IN JOB A ���
enBldgs Certified copy is hereby furnished New Residtial Bid & Pools EACH NO ` FEE ADDRESS J��
Certified copy is filed with the county building inspec + 1 & 2 Family Sq Ft $ — $ LOCALITY
ti n department Multi family Sq Ft ' NEAREST
1 /t Residential Swimming Pools -
CROSS ST P%
Date � ApplicanMNSURANCE
OWNER OR ��'p �
FIRM NAME Iw! �, /u
CERTIFICATE OF EXEMPTIORKERS Outlets RecLightSv MAIL
COMPENSATION ADDRESS
First 20
(This section need not be completed if the work involved by Total No Additional CITY Tel No
the permit is for one hundred dollars ($100)or less )
PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
so as to become_subject to the Workers Compensation Laws Lighting Fixtures First 20 1Z ADDRESS
Total No -)- - Additional t CITY SY Tel No
Date Applicant Fixed Appliances Not Over 1 HPPERMIT J�
NOTICE TO APPLICANT If after making this Certificate of APPLICANT/ \Ste'
Glun-
Exemption you should become subject to the Workers Range_ Heater_D W _ �,l
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M — ADDRESS313 �utiT(NGie�t) PP_
with comply with such provisions or this permit shall be Top — FAU W H — '/
deemed revoked ( Hood _ Fan Other— CITY "I A, Tel No Lrt� 1Z
LICENSED CONTRACTORS DECLARATION LICENSE OR �D�S
I hereby affirm that I am licensed under provisions of Chapter 9 Disp = Roo
6 A A(15r- REG NUMBERq'I Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO i PROCESSE BY
and Professions Code and my license is in full force and effect Power Apparatus & Large Appliances
Size &Type HP KW KVA or KVAR 0
License Numbe Lic Class-IS Up to 1 Incl — FINAL FINAL /� �
g( -at
Over 1 to 10 Incl DATE
Contra�tdrl�(SG*,')4at- ' ate VALI ATION 0
❑ Over 10 to 50 Incl FIN U
I am exempt under Sec Over 50 to 100 Inc BY
B &P C for this reason Over 100 N
Services Swbd MCC& Panelboards Z
Date 0 200 Amp Under 600 V X 7 5 4.7 A
Signature 201 1000 Amp Under 600 V -
❑ Over 1000 Amp or Over 600 V # o a o e o 2
I
Exemption fo Reg Maint Elect
SINGLE FAMILY Temp Power Pole&Appurtenances ( ° ° 2 2 2 5
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit A =
I hereby affirm that I am exempt from the Contractor s License AdditionahSign Branch Grcuits o 0 0 222 5 c0
Law for the following reason (Section 7031 5 Business and
Professions Code) I1 0 _
El as owner of the property will do the work and the Misc Conduits & Conductors 0728-87
il
structure is(not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ® L
7044 Business and Professions Code)
f
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) _
(Sec 3097 Civ C ) - _ I 17,51
' PLAN CHECKING FEE
y t
Lender s Name AJIA=
PERMIT ISSUING FEE
Lender s Address s J
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 jaws regulating Electrical wiring and t
hereby authorize representatives of this'County to enter upon j
th a ve menti° d property for inspection purposes
l jSEE REVERSE FOR EXPLANATORY LANGUAGE --
Sig ure o Permittee Date
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