HomeMy Public PortalAbout5008ALESSANDRO AVE_Electrical (5) DEC
TION
WORKWS`.CI havNSATION cafe R c'.nse 76A663 DPW 3187 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate.of consent to self ce e�o6G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
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
F-1Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY I )
NEAREST
tion department. ' Multi-family Sq. Ft. l�'
Residential Swimming Pools OWNER OR
Date "' Applicant FIRM NAME 4' f
CERTIFICATE OF EXEMPTION FROM WORKERS' ORQ � MAIL
utlets: ec�Light Sw. --
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No.;2e 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'Compens avis, Lighting Fixtures First 20 ADDRESS
`q Additional
Notal No. CITY Tel. No.
Date Applicant �ed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, aft making this Cert icate of APPLICATION J-_7
C
Exemption, 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 p14
with comply with such provisions or this permit.shall be Top FAU —W.H. —
deemed revoked. CITY Tel. No. S'G Q C/
LICENSED CONTRACTORS DECLARATION Hood — Fan —Other— v /
Disp. — Room Air Cond. — LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER �" Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT,7�1Q P ESSED B >_
and Professions Code,and my license is in full force and effect. %7 o
� d
r- / �a _ Size &Type HP, KW, KVA, or KVAR v Q
License Number 1,J CJf�✓ ic. Class rL. Up to 1 Incl. FINAL U
Contractor l' Date - Over 1 to 10 Incl. DATE �2`� VALID TION 0
Over 10 to 50 Incl. FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. FI / G" W
B.&P.C. for this reason Over 100
�'
Services, Swbd., MCC & Panelboards Z
L/P Z
Date: 0-200 Amp. Under 600 V 7J
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 r•
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit �A�_`•T°.a
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 3 - t6.20
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors 1 ITEMS
,EM:•.
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— ® TOTAL
56Q20
e
Business and Professions Code). 56.10
CONSTRUCTION LENDING AGENCY CASH
I hereby affirm that there is a construction lending agency for (fiANGE °!?I
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name N/�-�j U✓� /� 0119CI{#`0001 1/299/90
Lender's Address
�QvO J�' fdV �� PERMIT ISSUING FEE o
t v('�0 8547 1 AN 9°43
1 certify that I have read this application and state that the TOTAL FEE • 40
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
th 5ove-me �nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
C1 Si atureoDate