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HomeMy Public PortalAbout5043ALESSANDRO AVE_Electrical (3) WORKERS' COMPENSATION DECLARATION 20A019DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O I hereby Oft rm that l Hywe a�ertjficat� of conceal'to Self .CE 86G insure, or a cerxif.icate of Workers-Com ensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec: 3800, La%. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB FICertified co is hereby furnished. EACH NO. FEE ADDRESS PY Y New Residential Bldgs. & Pools Certified co is filed with the count building inspec- 1 & 2-Family, S Ft. LOCALITY PY Y 9 P Y� 4� � — $ F-Ition department. Multi-family Sq..Ft. — NEAREST CROSS ST. Residential Swimming Pools Date A PP licant OFIRM NAMEe V f WNER OR /!LIP / JA CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec2y Light�Sw. R MAIL !' COMPENSATION INSURANCE 'ADDRESS � First (This section need not be completed if the work involved by 20 Total No.—�� Additional CITY /P ��'7 Tel. No.?��-_`'e1 the permit is for one hundred dollars ($100)or less.) PLAN CHECK. 1 certify that in the performance of the work for which this rAPPLICANT 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 Additional Date Applicant Total No.' CITY Tel. No. NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION Compensation provisions of,the Labor Code, you must forth- Oven — Dryer —W.M.— 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. Class. REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PRO SED B and Professions Code,and my license is in full force and effect. K 0 Size&Type HP, KW, OVA, or KVAR5. Q License Number Lic. Class O U Up to 1 Incl. FINAL Contractor Date Over 1 to 10 Incl. DATE �j VALIDATION cc ElOver 10 to 50 Incl. FINAL I am exempt under Sec. Over 50 to 100 Inc. BY U Over 100 LLJ B.&P.C. for this reason d Dates Services, Swbd., MCC& Ponelboards Z Z 0-200 Amp: Under 600 V — Signature 201 - 1000 Amp. Under 600 V O Over 1000 Amp. or Over 600 V r Exemption for Reg. Maint. Elect. 0 SINGLE FAMILY Tem Power Pole &Appurtenances i s HOME OWNER-BUILDER DECLARATION p' PP lyl_CT. I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits �Ll�e `f .30 Xissions Code): i Misc. Conduits&Conductors ITEMS , as owner of the property, will do the work and the TOTAL #'F ' structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ ® r Business and Professions Code). { y i•e,r;_I CONSTRUCTION LENDING AGENCYCGEHAN w `(1 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.). 101 _00-01110 ti �' 1 I PLAN CHECKING FEE Lender's Name 31r`11 1 � 4 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 re ating Electrical wiring, and her by authorize representatJ e of this County to enter upon t a ve- 'entione eor inspeYj ton purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE ©s Sig ature of rrry ft a Date ��