HomeMy Public PortalAbout5510ALESSANDRO AVE_Electrical WORK11 ERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE-806G
or a certIicate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab. C.) `fl
Policy No. Company FOR APPLICANT TO FILL IN JOB �� e� ����� w D��
Certified co is hereby furnished. EACH NO. FEE ADDRESS U f�
PY Y New Residential Bldgs.& Pools
S — $ /
Certified copy is filed with the county building inspection 1 & 2-Family, q�Ft. $ LOCALITY T
department. Multi-family Sq.Ft. — NEAREST
CROSS ST. VJ
Date Applicant
Residential Swimming Pools OWNER OR �A J _-/ / N
FIRM NAME /(� h
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light — Sw. — MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars ($100)or less.) Total No. Additional CITY Tel.No.
I certify that in the performance of the work for PLAN CHECK 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
�t
Total No. Additional
Date / V Applicant .K 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'Compensation Range_ Heater_ D.W. _ APPLICANT
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.
LICENSED CONTRACTORS DECLARATIONCITY Tel.No.
Hood — Fan Other_
I hereby affirm that I am licensed under provisions of Chapter 9LICENSE 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. Power Apparatus& Large Appliances DISTRICT NO'/� fx/ PRO ED¢
Size & Type HP, KW, KVA,or KVAR V 0✓ ' O
License Number Lia Class Up to 1 Incl FINAL n U
Over 1 to 10 Ind. DATE• 11-9 �1 ) �
Contractor Date �/ VALIDATION 0
❑ Over 10 to 50 Incl.
I am exempt under Sec. Over 50 to 100 Inc. BY AL W
BAP.C. for this reason Over 100 Q
Services,Swbd.,MCC& Panelboards ® N
Date: _-,0- 200 Amp.Under 600 V Z
Signature 201 - 1000 Amp.Under 600 V
❑ ti
Exemption for Reg.Maint.Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit `-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 t�C � .a
Code): Misc.Conduits & Conductors 3307 36.00
LJ I,as owner of the property,will do the work and the structure 1 ITEMS
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t i
and Professions Code), 0. TIT
CONSTRUCTION LENDING AGENCY CHECK 6.00
1 hereby affirm that there is a construction lending agency for the CHANGE ° }j
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
Lender's Name PLAN CHECKING FEE 130130-01001 7/20/90
PERMIT ISSUING FEE 1949 1 AM
Lender's Address 8°2•-I
1 certify that I have read this application and state that the above TOTAL FEE 6.100
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.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date _