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HomeMy Public PortalAbout5043ALESSANDRO AVE_Electrical (2) WORKERS' COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self Ce 8006G 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 INJOB O no ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO, FEE ADDRESS $ _❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ LOCALITY � j tion department. Multi-family Sq. Ft. NEAREST f Residential Swimming Pools CROSS ST. Date Applicant OWNER OR 1 FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec�LightSw. MAIL COMPENSATION INSURANCE First 20 • D Q b ADDRESS (This section need not be completed if the work involved by Total No. Additional CITY Tel. No. 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 so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 f © 6-2' 6' ADDRESS Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION D0 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.— O ADDRESS with comply with such provisions or this permit shall be Top . — FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY Tel. No. LICENSED CONTRACTORS DECLARATION LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. (commencing with Section 7000)of Division.3 of the Business Power Apparatus& Large Appliances DISTRICT NO. P O '6SED BY >_ and Professions Code,and my license is in full force and effect. a_ Size &Type HP, KW, KVA, or KVAR (((JJJ Q License Number Lic. Class Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE �s1 a VALIDATION � Contractor Date Over 10 to 50 Incl. FINAL ii 0 ❑ I am exempt under Sec. Over 50 to 100 Inc. BY _ U Over 100 LL B.&P.C. for this reason '�" � Services, Swbd., MCC& Panelboards ® N'„.i.§ , Z Date: 0- 200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V -„ ” °.`t:_S ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. TOTAL _ L SINGLE FAMILY += .L HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances Sign with One Branch Circuit i i I hereby affirm that I am exempt from the Contractor's License Sig -''''`'I Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits L;) (�I j� ly I Professions Code): °"" ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors Other See Complete Fee Schedule , '`I?R_= `= =_ structure is not intended or offered for sale(Section 7044, ( P )— . .,•. s Business and Professions Code). _ j.- _ ° 5, CONSTRUCTION LENDING AGENCY 10 I 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 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 represent es of his County to enter upon - -� the bove- ention ro ._for ,rtspe "ction purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 9 0 � i tee Date ©s