HomeMy Public PortalAbout4942ALESSANDRO AVE_Electrical (3) WORKERS' COMPENSATION DECLARATIO+r , CE-80 1018;#- APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of ce-is+;n•t ta.If CE-806fr_. ��
insure, or a certificate of Workers' Compensation Insurance, S COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab.,C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO, FEE ADDRESS
❑ 1 & 2-Family, S Ft. $ t — $ LOCALITY
Certified copy is filed with the county building inspec- Y• q�
tion department. Multi-family Sq. Ft. — NEAREST _
Residential Swimming Pools CROSS ST.
OWNER OR
Date Applicant FIRM NAME % AJi
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec MAIL
COMPENSATION INSURANCE First 20 ADDRESSLight Sw._ --
` %
(This section need not be completed if the work involved by Total No. CITY , Tel. Na.
the permit is for one hundred dollars ($100)or less.) Additional 'Z
that in the performance of the work for which this PLAN CHECK
I certify P 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 ADDRESS
Additional CITY Tel. No.
pp Total No.
���xemption,
ate Applicant Fixed Appliances Not Over 1 HP PERMIT 1,
OTICE TO APPLICANT: If, after making this Certificat of APPLICANT / 4/ J7�
you should become subject to the Workers' Range_ Heater_D.W. —
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood Fan _ Other— CITY / � Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESS D BY >_
and Professions Code, and my license is in full force and effect. d
Size & Type HP, KW, KVA, or KVAR O
License Number Lic. Class Up to 1 Incl. FINAL V
09
Over 1 to 10 Incl. DATE _ `-� 0
Contractor Date FINA J VALIDATION O
❑ Over 10 to 50 Incl.
I am exempt under Sec. Over 50 to 100 Inc. BY W
a
Over 100
B.&P.C. for this reason rA
i Z
Services, Swbd., MCC & Panelboards
Date: 0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and 2 0 8 3.4 A
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits& Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044, Business and Professions Code). , • • 2 5 0
CONSTRUCTION LENDING AGENCY • • • 2 5 Jr 0
1 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) 1 005-84
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address C
I certify that I have read this application and state that the TOTAL FEE �J
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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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nature of Permittee Date