HomeMy Public PortalAbout5731ALESSANDRO AVE_Electrical WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91)
76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby abfirm that I have a certificate of consent to self insure,
d>a certificate of Worker's Compensation Insurance', or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab. C.) ��//••�1��
Policy No. Company�L�� � FOR APPLICANT TO FILL IN JOB
ADDRESS 5--73/. 4 Lr=ssDj(�
El
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
$ $ LOCALITY
❑ Certified co Is filed with the count building inspection 1 &2-Family,Sq.Ft.
PY Y 9 P NEAREST 01
C/depar ment. y7, Multi-family Sq. Ft. CROSS ST.
Date / Applicant /y Residential Swimming Pools ASSESSOR
/n MAP PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec/v Light Sw. OWNER OR
COMPENSATION INSURANCE FIRM NAME
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(This section need not be completed if the work involved by the /V0MAIL
,� First 2Additional ADDRESS
permit is for one hundred dollars(5100)or less.) Total No. �"
I certify that in the performance of the work for which this permit CITY Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 '� APPLICANT
Total No. Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
PERMIT
provisions of the Labor Code, you must forthwith comply with such ` �Ua
provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. }
NSE OR
Over 50 to 100 Incl. REG.NU BER Class.
O J� Over 100 DISTRICT NO. PROCESSED BY C)
License Number� (� Lic.Class C)
Services,Swbd.,MCC&Panelboards Cc
(j 0-399 Amp. Under 600 V FINAL O
Contractor Date DATE V
El I am exempt under Sec. 400-1000 Amp.Under 600 V �i LLI
VALIDATION
Over 1000 Amp.or Over 600 V FINAL 11
B.&P.C.for this reason BRANCH CIRCUIT FEES BY W
Date: 15A,or 20A, 120V,Lighting or Recept. Z
e?� 1 To 10 Branch Circuits 7/0 '�
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits `j
i
SINGLE FAMILY Temp. Power Pole&Appurtenances s
HOME OWNER-BUILDER DECLARATION ACCT.9'
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit _, .,
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3303 E�e._e
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Code): 1 ITEMS
❑ I, as owner of thepro ert will do the work and the structure Misc.Conduits&Conductors �-
is not intended orof offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 85 m to
and Professions Code). ► CHECK 85,50
CONSTRUCTION LENDING AGENCY CHANGE .00
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.) PLAN CHECKING FEE 0-000--0001 4/ 83/96
Lender's Name 5768 1 AM 9:35
PERMIT ISSUING FEE ' O
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE �
that the 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 inspect'on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
,. � 2
SIGNAdUR OF PE z DATE