HomeMy Public PortalAbout5048ALESSANDRO AVE_Electrical (3) irm that
COMPENSATION DECLARATION 76-663 10/61 APPLICATION FOR ELECTRICAL PERMIT
,.,•,L.he *cificate
tfirm thatat I have a certificate of consent to self insure, CE-806G
or a of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof fSec.3606,gab. C.) fl
Policy No. Company FOR APPLICANT TO FILL IN JOBD yG J
,❑. Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs.& Pools
Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ — $ LOCALITY
department. Multi-family Sq.Ft. — NEAREST
CROSS ST.
Residential Swimming Pools D S cyl
Date Applicant OWNER OR
! FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' � d 1 MAIL
Outlets:Rec Light Sw. —
COMPENSATION INSURANCE /�U� ADDRESS
(This section need not be completed if the work involved by the ' �, First 20 ` CITY Tel.No j
permit is for one hundred dollars ($100)or less.) Total No. Additional lap
PLAN CHECK
I certify that in the performance of the work for which this permit APPLICANT
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
j, ,� ,n Total No. Additional
�-- tS� CITY Tel.No.
Date Applicant u�tiFixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, afte making this ertificate of PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
,
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS
r
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _
. LICENSED CONTRACTORS DECLARATION Hood — Fan � OtherCITY Tel.No.
_
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR '
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER Class.
Professions Code,and my license is in full force and effect. DISTRICT NO. PROC SSED BY/
Power Apparatus& Large Appliances
Size & Type HP,KW,KVA,or KVAR �� G
License Number Lic.Class
Up to 1 Incl. FINAL ,,yy��
Over 1 to 10 Incl. DATE
Contractor Date ((JJ ���OOJJJJ VALIDATION 0
❑ Over 10 to 50 Incl. FIN
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 0-
i��
Services,Swbd.,MCC&Panelboards ) Z
Date: 0- 200 Amp.Under 600 V f
Signature 201 - 1000 Amp.Under 600 V ;29 4 6 8 A
❑ Exemption for Reg.Maint.Elect. Over 1000 Amp.or Over 600 V # o o:o o o 2
SINGLE FAMILY Temp.Power Pole& Appurtenances II o - 39.50
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit '010 o39,505
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): o4,271-88
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)
and Professions Code). ,
CONSTRUCTION LENDING AGENCY
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
Lender's Name
PERMIT ISSUING FEE
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
representatives of this County to enter upon the above-mentioned
propAty for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
a Lf—,2—?
Si na ure of Permit& Date