HomeMy Public PortalAbout5315ALESSANDRO AVE_Electrical � j r
' . WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT G L
hereby''affirm that"I have a certificate of consent to self insure, CE-806G 1115
d It c�
o4a,cer ificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY.. (/
copy thereof(Sec.3800,Lab. C.)
Policy No. - Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is herebyfurnished. EACH NO. FEE ADDRES
New Residential Bldgs. & Pools
❑ Certified co 1 & 2-Family,Sq.Ft. $ — $ LOCALITY
copy is filed with the county building inspection
department. Multi-family Sq.Ft. NEAREST �y r—
CROSS T.
Residential Swimming Pools OWNER OR
Date Applicant. FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light -4 � ' '
Sw. — y^�+ AIL
COMPENSATION INSURANCE _ ADDRESS
(This section need not be completed if the work involved by the First 20 � +, - GITY'�—
permit is for one hundred dollars($100)or less.) Total No. Additional l� Tel.No.
1.certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall not employ any per in any manner so as to APPLICANT
become sub' t to th Workers'Co e sati n Laws Lighting Fixtures First 20 ADDRESS
/ �-RfApplicaAw
����2Additional
/� � Total No. CITY Tel.No.
Date Fixed Appliances Not Over 1 HP PERMIT
NOTICE/TO PPLICANT: If, after making this Certifica of
APPLICANT
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. CITYL!w-wr
LICENSED CONTRACTORS DECLARATION Hood — Fan — Other_
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSEOR
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. REG.NUNiBER� QfiS� Class. (�
Professions Code,and my license is in full force and effect. DISTRICT NO. PROCESSED BY
Power Apparatus& Large Appliances
/ /J//eg Size& Type HP,KW,KVA,or KVAR �� Q
License Numbe �jj Lia Class (�'
Up to 1 Incl. FINAL
// Over 1 to 10 Incl. DATE v�
Contracto Date�r7L���Je�IPY / VALIDATION
❑ / Over 10 to 50 Inc].IlFINA
I am exempt under/_- Over 50 to 100 Inc. g
BAP.C.for this reason Over 100
N
Date:
Services,Swbd.,MCC&Panelboards , Z
0- 200 Amp.Under 600 V
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 Sign with One Branch Circuit
ereby affirm that I am exempt from the Contractor's License Law9 4 7, 1 .A
the following reason(Section 7031.5, Business and Professions . Additional Sign Branch Circuits
ode): # o'0 0 0 0 2
❑ Misc.Conduits & Conductors
I,as owner of the property,will do the work and the structure o -1 5.7 5
is not intended or offered for sale (Section 7044, Business Qther(See Complete Fee Scheou le) ,
and Professions Code).
CONSTRUCTION LENDING AGENCY V 0 0 0 1 5�] 5
I hereby affirm that there is a construction lending agency for the 0 4,2 7 `�a
berformance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
C.).
PLAN CHECKING FEE
S ender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE J
information is correct. I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize
e sentatives of this my to enter upon the above-mentioned
o erty for inspectio rposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
,ignature of Permittee Datind