HomeMy Public PortalAbout5342ALESSANDRO AVE_Electrical WORKERS'COMPENSATION DECLARATION CE 806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY �.
insure, or a certificate of Workers'Compensation Insurance,or
a certified copy thereof(Sec. 3800,Lab. C.)
Policy No. Company
FOR APPLICANT TO FILL IN
New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — Is I LOCALITY i Irf1 I
❑
Certified copy is filed with the county BuilMulti-family Sq. Ft. NEAREST
ding inspection CROSS ST Q j VE
department. Residential Swimming Pools OWNER OR
FIRM NAME
Date— Applicant Outlets: Rec.—Light— Sw. MAIL 1",
First 20 ADDRESS r
L�-V'_ l�I Y C1
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional CITY-J ' //1� Tel No.
COMPENSATION INSURANCE �1 ��
PLAN CHECK d
APPLICANT
(This section need not be completed if the work involved O
by the permit is for one hundred dollars Fixtures First 20
s ($100) or less.) ADDRESS U
Total No. Additional
I certify that in the performance of the work for which this CITY O
permit is issued, I shall not employ any person in any manner Fixed Appliances Not Over 1 HIP I
PERMIT U
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT Ul
CL
Oven _ Dryer_W.M. ADDRESS N
Date Applicant Top _ FAU _W.H.._ Z
Hood _ Fan _Other_ CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond.— LICENSE OR
Exemption, you should become subject to the Workers' REG. NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PROCE ED BY
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP, KW, KVA,or KVAR (/
Up to 1 Incl. 9
Over 1 to 10 Incl. FINAL
DATE
LICENSED CONTRACTORS DECLARATION VALIDATION
Over 10 to 50 Incl. � _ ;
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL , c
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY `�Y
ness and Professions.Code, and my license is in full force and
effect. Services
0-200 Amp. Under SIO_V ��
License Number Lic. Class 201-1000 Amp.Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V
HOMEOWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code):
® 1 2,J
Misc.Conduits&Conductors
I, as owner of the property, will the work and the Other (See Complete Fee Schedule)— ,0 b o 0 0 G
structure is not intended or offered for sale (Section ,
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY 2 0 0 1950
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is o 0 0 1 9,5 0=
PERMIT FEE (Sub-Total)
issued (Sec. 3097,Civ.C.). �, 13-81
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
ILender's Address PERMIT ISSUING FEE
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 t/ do
ordinances and State laws regulating Electrical wiring,.and
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig` lure of Permittee Date
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