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HomeMy Public PortalAbout5745ALESSANDRO AVE_Electrical /17 N WORKERS' COMPENSATION DECLARATION r"5)Pw3i87 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self C tCG insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab C.) Policy Nol Company 5� ��j/= jam!° FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. Cm'�' /d2 New Residential Bldgs. & Pools EACH NO. FEE ADDRESS Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. FT. NEARESTCROSS ST. �" �-_� ( ��,� Residential Swimming Pools OWNER T. //1�1 Date J Applicant FIRM NAME /'tel /1 CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec LighT Sw._ MAIL COMPENSATION INSURANCE ADDRESS 6 (This section need not be completed if the work involved by Total No. AddiFirst tional CITY Tel. No.y-t 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 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 © L,.[.p" Exemption, you should become subject to the Workers' Range— Heater—D.W. — n Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS /' C7 �Z 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 Disp. Room Air Cond. REG. NUMBER Class. 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 NO. PR ESSED BY >_ and Professions Code,and my license is in full force and effect, d Size &Type HP, KW, KVA, or KVAR 0 O License Number_? �/y J Lic. Class CZ` rn 7 Up to 1 Incl. FINAL U Contracto -�r'v i- `� "C�' Over 1 to 10 Incl. DATE �` VALIDATION Date Over 10 to 50 Incl. J ❑ FIN n 0 // I am exempt under Sec. Over 50 to 100 Inc. U gY a W B.&P.C. for this reason Over 100 aU)Services, Swbd., MCC& Ponelboards , Z Date: 0- 200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances Q I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit 3_ Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 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)_ , i;E-r•: t-=. .Business and Professions Code). r CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for -i sl is ism =1�' the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE Lender's Name NVII ` ''t j'_;;+,-E='a¢J. PERMIT ISSUING FEE Lender's Address / ==' I certify that I have read this application and state that the TOTAL FEE 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 above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE v!14, a a� at r of Permittee Date ©s