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HomeMy Public PortalAbout5043ALESSANDRO AVE_Electrical (4) WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT _'t•5ereby affirm that I have a certificate of consent to self cE eo�tc insure, or a'certificafe of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Pdiic No. Company FOR APPLICANT TO FILL IN JOB EJ Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS�O/t 3 liteSsajOro Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY ` tion department. Multi-family Sq. Ft. NEAREST CROSS ST. Date Applicant Residential Swimming Pools OWNER OR FIRM NAME � 1i��►�1 �1� , CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec I Li ht Sw._ MAIL ,,II /� r1 COMPENSATION INSURANCE ' 9 s } ` C ADDRESS (2 ;J �QSSt� This section need not be completed if the work involved b First ti CITY I Qi G'r ( P Y Total No. Additional � t�/ 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 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 Dis — Room Air Cond. — LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 p REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. PROCESSED BY >_ and Professions Code,and my license is in full force and effect. a- Size &Type HP, KW, KVA, or KVAR �a License Number Lic. Class Up to 1 Incl. FINAL LGt .L•,e�� Q Over 1 to 10 Incl. DATE � VALIDATION 0 Contractor Date 0 1-- F-1 Over 10 to 50 Incl. FINALS Q 0 I am exempt under Sec. Over 50 to 100 Inc. BY // U Over 100 LLJ B.&P.C. for this reason t1 Services, Swbd., MCC& Panelboards ZZ Date: 0- 200 Amp. Under 600 V01110� — Signature 201 - 1000 Amp. Under 600 V ID Over 1000 Amp. or Over 600 V Exemption for Reg. Maint, Elect. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances y _ 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 Professions Code): iti4, l i 91, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ 1 0IAL Business and Professions Code). r NECK CONSTRUCTION LENDING AGENCY 'BECK -1 K I hereby affirm that there is a construction lending agency for N GE .1`I�' the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). 714 Lender's Name PLAN CHECKING FEE PERMIT ISSUING FEE ,9 t� Lender's Address I certify that I have read this application and state that the TOTAL FEE 10 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 inspection purposes. /t51 SEE REVERSE FOR EXPLANATORY LANGUAGE J1 1 Signature of rmi tee Date ©s