HomeMy Public PortalAbout5531ALESSANDRO AVE_Electrical (2) WORKERS COMPENSATION DECLARATION 63 10/81
rl- hr,,.by APPLICATION FOR ELECTRICAL PERMITffirm that I have a certificate of consent to self CE 8066inCE 8 a
urse or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C )
Policy No Company 1 FOR APPLICANT TO FILL IN JOB 9
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS ..)El �3 /EsJ'/�ot1 b/l0 4
— me
Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ $ LOCALITY Cc /,9
tion department Multi family Sq Ft —
NEAREST
Residential Swimming PoolsCROSS ST J
Date A OWNER OR
Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw_ AMAIL
DDRESS J$ ��ssot7i6/,�0 /9v�
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by Total No Additional CITY , 7' Tel No b.7_5'd F21-
the permit is for one hundred dollars ($100)or less)
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I certifythat in the performance of the work for which this PLAN C E
P APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensat n Laws Lighting Fixtures First 20 ADDRESS
4ZUTotal No Additional
FC/ CITY Tel No
ate " Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making thisemficate of APPLICANT
Exemption you should become subject to the Workers Range_ Heater_D W _
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 LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PRO SED BY
and Professions Code and my license is in full force and effect d
Size & Type HP KW KVA or KVAR Q
License Number Lic Class Up to 1 Incl FINAL V
Over 1 to 10 Incl DATE G�-17 VALIDATION Q
Contractor Date Over 10 to 50 Incl
FINAL V
I am exempt under Sec Over 50 to 100 Inc BY 1W
IL
B &P C for this reason Over 100 Z
Date Services Swbd MCC& Panelboards
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V
❑ 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 Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and
Professions Code)
Misc Conduits& Conductors a G 2 u A
I as owner of the property will do)the work and the I
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► # o o a o c 2
7044 Business and Professions Code) �o 0 2550
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for, I 0 0 0 2 5 5 0 5
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) 7'1 b—8 4(Sec 3097 Civ C ) r
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE �
Lender s Address
I certify that I have read this application and state that the TOTAL FEE T" ^
above 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
`Signatura 1 � � � SEE REVERSE FOR EXPLANATORY LANGUAGE
e of Permittee Date
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