HomeMy Public PortalAbout5031ALESSANDRO AVE_Electrical (2) WORKERS'COMPENSATION DECLARATION 20A019DPW 3/87 ,APPLICATION FOR ELECTRICAL PERMIT O
I hereb} affirm that I have a certificate of consent to self CE 8066
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 y a
Certified copy is hereby furnished. New Residential Bldgs. & Pools
EACH NO. FEE ADDRESS �/ ✓/ L�SS�1 v U O
❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY
tion department. Multi-family Sq. Ft. NEAREST Q
CROSS ST. 0CVe,, l/
Date A licant Residential Swimming Pools OWNER OR
PP 77 FIRM NAME / 1/ /
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�Light Sw.J v ADD
COMPENSATION INSURANCE MAIL S�Q�I
/� First 20 PLE n/
(This section need not be completed if the work involved by Total No.1_.L Additional CITY � C_ T/ Tel.
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 Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensation Laws.
Additional
Total No.� CITY Tel. No.
Date 1 Applicant ,�!,4 Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, of r makingthis ertificate of PERMIT
APPLICATION /lej5�eA.11G[/ 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 �<0/24
with comply with such provisions or this permit shall be To — FAU W.H. —
deemed revoked. Hod — Fan Other— CITY /Cp �vE�2� Tel. No.Xr 9/9.3fL
LICENSED CONTRACTORS DECLARATION 1 LICSJ /ENSE OR a17�
/�Q p
Disp. — Room Air Cond. L REG. NUMBER /VJ 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 d
and Professions Code, and my license is in full force and effect.
Size&Type HP, KW, KVA, or KVAR 0
License Number Lic. Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE �' ' ( i VALIDATION 0
Contractor Date !—
❑ Over 10 to 50 Incl. FINAL
I � exempt under Sec. Over 50 to 100 Inc. BY C� W
Over 100 ( ✓ t1
B.&P.C. for this reason (n
Date:
Services, Swbd., MCC& Panelboards ► Z
0- 200 Amp. Under 600 V
Signature - 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole &Appurtenances
HOME 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): 6
❑ 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)_
Business and Professions Code).
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency fort
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 Di
PERMIT
PERMIT ISSUING FEE
Lender's Address Y' L H''
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 property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig ature of Permitte6 Date
I �