HomeMy Public PortalAbout4942ALESSANDRO AVE_Electrical (4) �BVORKERS'COMPENSATION DECLARATION -663 10/81 APPLICATION FOR ELECTRICAL PERMIT
ItrCE-aosG eby affirm that I have a certificate of consent to self insure,
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
❑ Certified copy is filed with the county building inspection 1 & 2-Family, Sq.Ft. $ $ LOCALITY
department. Multi-family Sq. Ft. — NEAREST
CROSS ST.
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CITY ,..: ;. 4 Tel. No.
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
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
Total No. Additional CITY Tel No.
Date Applicant '- mac' "^" Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
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 Tel.No.
LICENSED CONTRACTORS DECLARATION Hood Fan Other_
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. — Room Air Cond. REG.NUMBER Class
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY O
Size& Type HP,KW, KVA,or KVAR U
W
License Number Lic. Class .I
Up to 1 Incl. FINAL _
Over 1 to 10 Incl. DATE Z O VALIDATION LL.
Contractor Date
❑ Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc.
BY
B.&P.C. for this reason Over 100 a
Services,Swbd.,MCC & Panelboards ,
Date: 0- 200 Amp.Under 600 V W
Signature 201 - 1000 Amp.Under 600 V H
❑ 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 Law
F for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code):
I,as owner of the property,will do the work and the structure Misc.Conduits & Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ,
and Professions Code).
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(Sec.3097, PERMIT FEE (Sub-Total)
Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
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
properf�j for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date