HomeMy Public PortalAbout5002ALESSANDRO AVE_Electrical (5) WORKERS'COMPENSATION DECLARATION -663 to/st APPLICATION FOR ELECTRICAL PERMIT
II ! hereby affirm than I have a cer!iticate of Consent to self insure, CE-806G
c?;a certificate of Workers' Compensation n Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy-lhereof(Sec.3800,Lab.C.)
Policy Ned. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
❑ Certified copy is filed with the county building inspection 1 & 2-Family, Sq.Ft. $ — $ LOCALITY L� gel
department. Multi-family Sq. Ft. — GROS ST l
CROSS ST. OU
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec— Light Sw. — MAIL Q
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20 i
permit is for one hundred dollars($100)or less.) Total No. Additional CIT t c fn el.
I certify that in the performance of the work for which this permit PLAN CHECKAPPLICANT
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
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
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 Disp. — Room Air Cond. LICENSE OR Class.
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. f PROCESSED Y
Size& Type HP,KW,KVA,or KVAR O 0
License Number Lic.Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE _ w
Contractor Date VALIDATION 0
❑ Over 10 to 50 Incl. )-.
FINAL V
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 N
Services,Swbd.,MCC & Panelboards Z_
Date: 0 - 200 Amp.Under 600,V
Poo-
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 1
I hereby affirm that I am exempt from the Contractor's License Law %r a
for the following reason(Section 7031.5, Business and Professions
Additional Sign Branch Circuits ACC"
ea
Code): ncp
~' Misc. Conduits & Conductors
I,as owner of the property,will do the work and the structure 1 i i N`
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). ® ;!_9_AL 33 = 00
CONSTRUCTION LENDING AGENCY) a� CHECK _ aCl' s„=
I hereby affirm that there is a construction lending agency for the t +�ht3 4 'V
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
PLAN CHECKING FEE
Lender's Name _ I1EI�I0-01101 10/26 �`D
PERMIT ISSUING FEE -mss— ;
Lender's Address 1353 � �� S:13='
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
propert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Ak
/6 -06 -9,
Signature o Per ittee Date