HomeMy Public PortalAbout5031ALESSANDRO AVE_Electrical (5) . WORKER'S COMPENSATION DECLARATION 20-0019 DPW(,2 91) APPLICATION FOR ELECTRICAL PERMIT
I heresy aff(rm th�l have a certificate of consent to self insure, 76A663
or a ce,iiiilecate 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 JOBEl /� ��/� 1 y/'�n/� C
ADDRESS OS /"( /-'tJJ040 i
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
❑ _ $ $ LOCALITY
Certified co is filed with the count buildin Ins ection 1 &2-Family,Sq.Ft.
pY y g p NEAREST
department. Multi-family Sq.Ft. CROSS s7.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL DO
CERTIFICATE OF EXEMPTION FROM WORKERS' LL ' OWNER OR
Outlets:ROC. Light Sw. FIPM NAME L
COMPENSATION INSURANCE O
First 20
(This section need not be completed MAIL
the work involved by the Total No.L Additional ADDRESS (� = /�/�.1���d A✓�
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY eM e
is issued, I shall not employ any person in any manner so as to PLAN CHECK 1
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
/�^/^Q� / ADDRESS
Date ! Applicant
NOTICE TO APPLICANT: If, of r making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP. CITY Tel.No.
Exemption, you should become s lect to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, u must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT y� Z��t 9
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS 1 RL. (�
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY ' .+ Zve�y� Tel.No. 066V
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl.
Q Over 50 to 100 Incl. LICENSE ��O�rt Class.
REG.NUMBER J a
License Number a 3 LiC.CIeSS Over 100 DISTRICT NO. PR SED BY 0
/� ,rte U
Services,Swbd.,MCC&Panelboards d/• �V
Contractor Date 0-399 Amp.Under 600 V FINAL 0
DATE
400-1000 Amp.Under 600 V �1
❑ eexempt under Sec. Z, Z Z, 7 VALIDATION V
Over 1000 Amp.or Over 600 V FINAL d
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
Date: 15A,or 20A, 120V, Lighting or Recept. 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 . .... .. _.._.
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances ,g
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law Sig3-303 . ,r'.,
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): (
T ITEMS
❑ I, as owner of the property, will do the work and the structure Misc.Conduits&Conductors 5 �'j
P P Y, TOTAL i�y-��. �-�, ca
is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). CHECK
CONSTRUCTION LENDING AGENCY �; l (1 ,_I ;
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)
Civ. C.)
PLAN CHECKING FEE {`E"L"I —L`#�j3 ! J 1/9"
Lender's Name 1958
111 Art 'io Ili
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE C�()
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 inspec' urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
,,Lt, l0 /-sem
$1 NATURE OF PER TTEE DATE -