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HomeMy Public PortalAbout5525ALESSANDRO AVE_Electrical (2) WORKERS COMPtNSRTION DECLARATION 20 DPW 76A663 APPLICATION FOR ELECTRICAL PERMIT 76A663 I hereby affirm that I have a certificate of consent to self ct ec 1 insure or a'cdrtificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS or a certified copy the (Sec 3800 Lab C ) Policy No Compbny FOR APPLICANT TO FILL IN JOB ❑Certified copy isFhereby furnished New Residential Bldgs & Pools EACH 1 NO FEE ADDRESS—$ z-- ke f ❑Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ — $ LOCALITY c L tion department Multi family$q Ft — NEAREOSSST Dae Applicant Residential Swimming Pools OWNEROR ���D�� �� ��tZ 7FIRM NAME,, CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light-LSw✓ MAIL COMPENSATION INSURANCE ADDRESS a4,C First 20(This section need not be completed if the work involved by Total No Additional CITY ( Tel No the permit is for one hundred dollars ($100)or less ) I certify that in he performance of the work for which this PLAN CHECK i 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 yyl�j` 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 Disp — Room Air Cond — LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER Class (commencing with Section 7000 of Division 3 of the Business ( 9 ) Power Apparatus 8 Large Appliances DISTRICT O PROCESSED BY >- and Professions Code and my license is in full force and effect [O O Size &Type HP KW KVA or KVAR 13- License Number Lic Class Up to 1 Incl FINAL!! �7 U Over 1 to 10 Incl DATE -Z i` r�f.� VALIDATION Contractor Date Over 10 to 50 Incl `C CC U 0 ❑ ~ I am exempt under Sec Over 50 to 100 Inc gy A U Over 100 L1J B&P C for this reason t1 Date Services Swbd MCC& Panelboards 0 0 l�LGA Z Z +0 200 Amp Under 600 V — Signature 201 1000 Amp Under 600V # e 0 0 0 0 2 ❑ Exemption for Reg Maint Elect O\.er 1000 Amp or Over 600 V '1 o 0,1600 SINGLE FAMILY Temp Power Pole & Appurtenances HOME OWNER BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit r o,o o 0 6.0 0 Law for the following reason (Section 7031 5 Business and Additional Sign�Branch Circuits o6,29-88 Professions Code) I 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)— Business and Professions Code) CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the w rk for which this permit is issued PERMIT FEE (Sub Total) (Sec 3097 Civ C ) � PLAN CHECKING FEE Lender s Name PERMIT ISSUING FEE Lender s Address Q I certify that I have read this application and state that the TOTAL FEE above'informotion is correct I agree to comply with all County ordinances an State laws regulating Electrical wiring and hereby atho a representatives of this County to enter upon the above t e pro erty for i pection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE natu e o ermine —T' Date ©s