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HomeMy Public PortalAbout5030ALESSANDRO AVE_Electrical (3) -WORKERS'COMPENSATION DECLARATION DPW 3/87 76A663 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self ce s�oac ' insute, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS cer i9ed copy thereof (Sec. 38 , Lab. C.)fl�G f1001v/C� �G,t�� • • T olicy No. Company '/GSL �t�Lfi FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. 0/9c�- New Residential Bldgs. & Pools EACH NO. FEE ADDRESS S 0 0 Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY �— P, ion depart ent. Multi-family Sq.'Ft. NEAREST /���s,,f� /` Residential Swimming Pools CROSS ST. Date y`{ Applicant/P%�'//L F/A�e�(A� '� g OWNER OR FIRM NAME O T CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec_1_0_Light__4j�_Sw.� MAIL COMPENSATION INSURANCE yyoob� First 20 i Q 06 ADDRESS (This section need not be completed if the work involved by Total No. i.L Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) K on I certify that in the performance of the work for which this APPLICANT //�9 O , 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 i 0 Total No. � CITY Cil Tel. No. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not ever 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater D.W. APPLICATION Compensation provisions of the Labor Code, you must forth- Oven — Dryer 1—W.M. O ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. deemed revoked. CITY Tel. No. Hood — Fan —OtherCITY CONTRACTORS DECLARATION LICENSE OR �t / Disp. — Room Air Cond. �. REG. NUMBERA S�7yI6 Class. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY >_ and Professions Code,and my license is in full force and effect. (� U /eJ� Size &Type HP, KW, KVA, or KVAR �a Q License Number Lic. Class l Up to 1 Incl. FINAL Contractor IA -4--s Over 1 to 10 Incl. DATE 0 �� 4.3,,JzVALIDATION Q ❑ Over 10 to 50 Incl. FINAL F- I am exempt under Sec. Over 50 to 100 Inc. FBY INAL O 100 LL1 Over B.BP.C. for this reason n- Z Servi �Panel�boards �Date: 0-200 Amp. Un — Signature 2 ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. _ SINGLE FAMILY Temp. Power Pole&Appurtenances a.•,_;. ME OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Sign with One Branch.Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 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 7044, Other (See Complete Fee Schedule)_ TOTAL :f � = 60 Business and Professions Code). , :.� CONSTRUCTION LENDING AGENCY _ I hereby affirm that there is a construction lending agency for `-.�[��'-sii3i: °=!`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 u z. _ PERMIT ISSUING FEE _ I'lfii� f_ Lender's Address 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 laws regulating Electrical wiring, and hereby authorize representatives of this County to enter upon the above-mentioned prop rty for inspectionp p'o�s-es. SEE REVERSE FOR EXPLANATORY LANGUAGE Sigrioture of er itte . Datc ©s