HomeMy Public PortalAbout5031ALESSANDRO AVE_Electrical (4) firm WORKER'S I have
COMPENSATION
ate of consent to 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
76A663
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS G`
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
El Certified &2-Family,Sq.Ft. — $ $
Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq. Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PAGE t9- PARCEL 4D
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light�Sw/O FFIIRM NgME
COMPENSATION INSURANCE First 20 O a ^
(This section need not be completed if the work involved by the MAIL
permit is for one hundred dollars($100)or less.) Total No. Additional al ADDRESS t.�"40/
I certify that in the performance of the work for which this permit CITY Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
/ Total No. Additional ADDRESS
//Date — Applicant , l / RESIDENTIAL APPLIANCES NOT OVER.3 HP.
NOTICE-TO A PLI NT: If, after making this Cer(ficate of CITY Tel.No.
Exemption,you should become subje t to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
previsions of the Labor Code, yo' must forthwith comply with such power Apparatus&Large Appliances P PLICA
�J
provisions or this permit shall b deemed revoked.
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS a ��
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. CITY Tel.
(commencing with Section 7000) of Division 3 of the Business and ��� 2G
Over 10 to 50 Incl.
Professions Code,and my license is in full force and effect. LICENSE oR �1 O }
Over 50 t0 100 Incl. REG.NUMBER /�O Clas� a
A G 2 Over 100 DISTRICT NO. P C SED BY
License Number CAI J Lic.Class �7 p ryyFy
o� Services,Swbd.,MCC&Panelboards �_!/a L�LGz� - �
Contractor Date i✓ 0-399 Amp.Under 600 V DATE NAL O
❑ exempt under Sec. 400-1000 Amp.Under 600 V �L. z W
Over 1000 Am or Over 600 V VALIDATION
P• FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Date: 15A,or 20A, 120V,Lighting or Recept. f Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
El
41 Or More Branch Circuits
Exemption for Reg. Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits "
SINGLE FAMILY Temp. Power Pole&Appurtenances —' "' '" jL'
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits f w -Z a�
Code): T
TEJ
1,
I,as owner of the property, will do the work and the structure Misc.Conduits&Conductors z, s ,
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) f`r I—
'» zt
and Professions Code). CHECK i!"t�^
L_ 1=t.`,s`t
CONSTRUCTION LENDING AGENCYt
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) C�/Q
Civ. C.)
PLAN CHECKING FEE
Lender's Name 1/ _ .—
PERMIT ISSUING FEE os (p O —�
Lender's Address �•
1 certify that I have read this application and under penalty of purjury state TOTAL FEE
that the 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 ins ction rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
X � a _��3
SIG TURE OF PEIjMI DATE