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HomeMy Public PortalAbout5703ALESSANDRO AVE_Electrical (4) reaffirm -WORKERS' COMPENSATION DECLARATION 76-663 to/St APPLICATI®N FOR ELECTRICAL PERMIT I hereby affirmirm that I have a certificate of consent to self insure, CE-806G or a certificate of Workers' Compen.Aioh Insw'ance, 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 9 n pp Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS 0 3 Ak ss k,,A v.� AvV . < — Certified 1 & 2-Family, Sq.Ft. $ $ LOCALITY copy is filed with the county building inspection NEAREST department. Multi-family Sq.Ft. (� CROSS ST. L t WC 0`'L'`a Date Applicant Residential Swimming Pools OWNER OR FIRM NAME RA- r 1+�ov j W Q"7 CERTIFICATE OF EXEMPTION FROM,WORKERS' MAIL ° COMPENSATION INSURANCE Outlets:Rec— Light— Sw. ADDRESS .(This section need not be completed if the work involved by the First 20 . Total No. Additional CITY Tel.N /?} Gj-Odle permit is for one hundred.dollars($100),or less.) PLAN CHECK I certify that in the performance of the work for 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 Additional Total No. CITY - Tel.No. Date Applicant Fixed Appliances Not Over 1 HP NOTICE TO APPLICANT: If, after making this Certificate of PERMIT APPLICANT W Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ © her J provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS((;,. ,-+b, - rt m Cres, , L provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ CITY Tel.No. LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE'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. DISTRICT NO. PROCE BY Power Apparatus& Large Appliances 5��•-/ G�1.' Size & Type HP, KW,KVA,or KVAR UX p License Number Lic.Class Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE 7 VALIDATION Q Contractor' Date Ind.Over 10 to 50 InC• U ❑ FINAL I am exempt under Sec. Over 50 to 1'00 Inc. By W BAP.C.for this reason Over 100 NI Services,Swbd.,MCC& Panelboards Z Date: 0- 200 Amp. Under 600 V e 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 4 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit y I hereby affirm that I am exempt from the Contractor's License Law ACC o•p for the following reason (Section 7031.5,Business and Professions Additional Sign Branch Circuits {'} Code): 330'}, ❑ I,as owner sof the property,will do the work and the structure Misc.Conduits & Conductors A ITEMS Other(See Complete Fee Schedule) is not intended or offered for sale (Section 7044, Business , ATOTL 31® 00 and Professions Code). � ti �t Y.� CONSTRUCTION LENDING AGENCY CASH 31.00 I hereby affirm that there is a construction lending agency for the ruw1� performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) CHANGE � Civ.C.). PLAN CHECKING FEE Lender's Name 0000-0001 ,3/?7/910 PERMIT ISSUING FEE Lender's Address 0� 7 73 1 1 AM 11: I certify that I have read this application and state that the above TOTAL FEE 31 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 propert or inspection urposes. SEE REVERSE FOR EXPLANATORY LANGUAGE 3 ,�7 o Signature f Permittee Date