HomeMy Public PortalAbout5019ALESSANDRO AVE_Electrical (4) 03
Nfirm that
COMPENSATION DECLARATION CE 806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE 806G �j
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY Iul
or a certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOBn
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS � L' JA
❑ 1 & 2 Family S Ft $ — S LOCALITY VA `
Certified copy is filed with the county building mspec Y q
p y q NEAREST
hon deportment Multi family S Ft K
Residential Swimming Pools CROSS ST /'L C'
Date Applicant OWNER OR i
FIRM NAME P1 11/ V
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw_ MAIL +
COMPENSATION INSURANCE First 20 ADDRESS J41'+!.
L n
(This section need not be completed If the work Involved by Total No Additional CITY `o (� ' Tel No a�'�7%J
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 mgDner
so as to bec me subject to the Workers Co ion La s Lighting Fixtures First 20 ADDRESS
P Total No Additional
CITY Tel No
Date lJe Applicant Fixed Appliances Not Over 1 HP PERMIT /1
NOTICE TO APPLICANT If after making this Certificate of APPLICANT
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
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 r
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER L y p� Class —�Q
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO P ED BY
and Professions Code and my license is in full force and effect Power Apparatus 8 Large Appliances //
Size &Type HP KW KVA or KVAR l� 8
License Number �� Lic Class l Up to 1 Incl FINAL M
I
¢lS Over 1 to 10 Incl DATE /fj VALIDATION 0
ContractS'
ate v v Over 10 to 50 Incl
FINA
F1v V
W
I am exempt under Sec Over 50 to 100 Inc BY CL
B 8P C for this reason Over 100 NZ_
Date Seri nelboards _
0 200 Amp Under
Signature 01 1000 Amp Under 600 V
❑ ' 1 (= �{U
Exemption for Reg Maint Elect Over 1000 Amp or Over 600V io0
SINGLE FAMILY Temp Power Pole &Appurtenances A
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 t0 Q
Law for the following reason (Section 7031 5 Business and
Professions Code) L ��
❑ 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)
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) f
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE [7
Lenders Address �_6
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
hereby auth resentatives of this County to enter upon
the obo ent d property for inspection rpose
SEE REVERSE FOR EXPLANATORY LANGUAGE
,s
Si of Permittee Date