HomeMy Public PortalAbout5037ALESSANDRO AVE_Electrical (2) WORKER'S COMPENSATION DECLARATION 9 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT
76A66
I hereby affirm that I have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
cop,"'thereof(Sec.3800 Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS O3
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
LOCALITY
_
r-1Certifiedcopy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ $
dedepartment. Multi-family S Ft. NEAREST
P Y q o CROSS ST. ZA a34
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.L5 Light 14 Sw.3� y I OWNER OR
COMPENSATION INSURANCE First 20 Ike) FIRM NAME
°
(This MAIL
section need not be completed if the work involved by the 7
permit is for one hundred dollars($100)or less.) Total No.��/ Additional �a _ADDRESS
I certify that in the performance of the work for which this permit CITY SAME Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK L•
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 t, O APPLICANT
Total No._ Additional
ADDRESS
Date Applicant 15 OR 20A120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should ,ld become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH PERMIT
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH APPLICANT
LICENSED CONTRACTORS DECLARATION ADDRES I�
I hereby affirm that I am licensed under provisions'of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH /G• O
(commencing with Section 7000) of Division 3 of the Business and CITY 07YTel.No.ZQ J 3 U
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR class. cc
Power Apparatus&Large Appliances REG.NUMBER
License Number Lic.Class Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PROCESSED BY
Up to 3 Incl. O W
Over 3 to 10 Incl. FINAL �-
Contractor Date DATE Z
Over 10 to 50 lhcl.
❑ I am exempt under Sec. Over 50 to 100 Incl. L VALIDATION —
Over 100 FINAL
B.&P.C.for this reason BY
Services,Swbd.,MCC&P�nQ[IJ aos 7 O
Date: 1 4W
0.-200 Amp.Under 0O!!00//l,
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
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 I 4
Code):
I I rs_t
I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) i„3 ;t My .a _
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the 4 tH'f-.2—
performance
''performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEE _ _
Lender's Name
PERMIT ISSUING FEE L `= i Ai 1 s
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE `
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
repr entatives of this County to enter on the above-mentioned
W
p p oseSEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICANT OR AGENT DATE