HomeMy Public PortalAbout5720ALESSANDRO AVE_Electrical (2) WORKERS' COMPENSATION DECLARATION 2o-ooteDPW 3ie7 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self �E enc
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
oratifip,, copy thereof (Sec. 3800, Lab. C.)
Polys:cAg_Company 1�*te-mpyt: FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS Z o v i
TY
❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALI7 t •'n
tion department. % ' Multi-family Sq. Ft. NEAREST
CROSS ST.
Date
I �� Applicant LJ Residential Swimming Pools OWNER OR t
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ AMAIL
DDRESS Ur}�
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by Total No. Additional CITY A Tel. No. _�
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT '/dL
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
Additional
Total No. CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: if, after making this Certificate of APPLICATION
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. CITY Tel. No,
Hood � Fan —Other_ m
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. Room Air Cond. REG. NUMBER (� Q Class. 1
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT N PR SSED a
and Professions Code,and my license is in full force and effect.
Size&Type HP, KW, KVA, or KVAR 0
License Number I^–ISn Lic. Class Up to 1 Incl. FINAL U
l Over 1 to 10 Incl. DATEr VALIDATION 0
❑
Contractor Date Over 10 to 50 Incl. O FINAL
I am exe t under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 d
Services, Swbd., MCC& Panelboards v U)
Date: ® . Z
0-200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ –
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole &Appurtenances Qa
HOME OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit -330., 33.DO
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits r _
Professions Code): y)EN°L
❑ I, as owner of the property, will.do the work and the Misc. Conduits&Conductors i C i T AL 3_113 = 00
structure is not intended or offered for sale Section 7044, Other (See Complete Fee Schedule)_ CHUCK
"s
13
Business and Professions Code).
CONSTRUCTION LENDING AGENCY CHANGE 031:1
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). t1 (�`I
PLAN CHECKING FEE �4
_
Lender's Name O ° `
PERMIT ISSUING FEEI k3 .iia%$ � i�=
Lender's Address
I certify that I have read this application and state that the I TOTAL FEE Q
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-mentiFned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
s.
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Signa ure Permittee Date l O