HomeMy Public PortalAbout5031ALESSANDRO AVE_Electrical (3) WORKERS' COMPENSATION DECLARATION CE-806 10/8I APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a cert_iffiiedd copy thereof (Sec. 3800, Lab. C.)
Policy No.. - �93� Company's-r/I iLGI�V� FOR APPLICANT TOFILL.IN JOB /
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
IR Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY
tion department. Multi-family Sq. Ft. NEAREST
CROSS ST. r
Residential Swimming Pools
Date Applicant UL `� /�/4�`f9 g OWNER OR ` 5
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESS SU3 19 tCSS QD(Q.
(This section need not be completed if the work involved by First 20
the permit is for one hundred dollars ($100)or less.)
Total No. Additional CITY /1N 4 Tel. No.aS-7_J�S
I certify that in the performance of the work for which this PLAN CHECK
APPLICANT
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
Total No. Additional
CITY 71K Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of .}
Exemption, you should become subject to the Workers' Range_ Heater_D.W. — APPLICANT G /t3?�
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer _ W.M.— ADDRESS J 3
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. CIT _ '_Tel. No., -/Z/y
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_
Disp. Room Air Cond. LICENS OR �ry r Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER p(7Yd� c:7_0
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. PROCESS D BY
and Professions Code,and my license is in full force and effect.
�7y a� Size & Type HP, KW, KVA, or KVAR'
License Number 721 A Lic. Class Up to 1 Incl. FINAL , t)---�� Over 1 to 10 Incl.
l�rn�� A ^� DATE �f -�r VALIDATION
Contractor 1� ' Date �� Over 10 to.50 Incl. FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100
Date:
Services, Swbd., MCC & Panelboards ►
0 -200 Amp. Under 600 V
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 0 3 3 5 A
I hereby affirm that I am exempt from the Contractor's License { 0 2
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits o c o 0
Professions Code): 12 c+0 2 E.5 0
❑ 1, 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)_ , o ;; 0 2'5 `0
7044, Business and Professions Code). , 0 - 4
CONSTRUCTION LENDING AGENCY
1 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)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE l�
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 property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
aK` - -�Y
Signature of Permittee Date