HomeMy Public PortalAbout5745ALESSANDRO AVE_Electrical (2) t WORKERS'COMPENSATION DECLARATION - 10/81
CE-806G APPUCATKO)N FOR ELECTRICAL PERMIT
••I hereby affirm that I'have a.certificate of consent to self insure, C
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.) fl
Policy No. ��L 9 Ompany S C"O. FOR APPLICANT TO FILL IN JOB �`
❑ EACH NO. FEE ADDRESS ,5'7 `"f S ��•�'S•5�N �+"
Certified copy is hereby furnished. New Residential Bldgs.&Pools LOCALITY
Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ _ $ LrA c C(i-
department. Multi-family Sq:Ft. NEAREST
CROSS ST.
��^.26--9Z An G Residential Swimming Pools S (�►��
Date Applicant ` ` OWNER OR D
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:RecLight , Sw. /Z, MAIL
First 20
COMPENSATION INSURANCE a ADDRESS
(This section need not be completed if the work involved by the
permit is for one hundred dollars($100)or less.) Total No. 87 Additional CITY Tel.No.
I certify that in the performance of the work for which this permit PLAN CHECK
is issued, I shall not employ any person in.any manner so as to - APPLICANT
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. I I Additional CITY Tel,No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of ��� ' �L Q r�
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. 1 APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer -LL. W.M.'- ADDRESS
provisions or this permit shall be deemed revoked. Top FAU L-W.O.
LICENSED CONTRACTORS DECLARATION1 CITY; 1��v 1p% .Tel.No. F3 k0�
Hood Fan Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. 0 0�0 LICENSE OR 32509 rD Class.
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force and effect. DISTRICT NO. PR C SED BY
Power Apparatus& Large Appliances
f1O G Size& Type HP,KW,KVA,or KVAR � O
License Number 3 Lic.Class Up to 1 Incl. FINAL U
r Over,1 to 10 Incl. DATE
Contractor_ U� f—CEICA •Date �9� � 2 Z- VALIDATION 0
Over 10 to 50 Incl. FINAL
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 N'
Services,Swbd.,MCC& Panelboards 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 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 Law
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits -!�•€,i°
Code):
1` 1 r'10 '
❑ I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors � �;+�
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) f 11_I:Sr
and Professions Code). , +v•--°8 �
€ Lm
CONSTRUCTION LENDING AGENCY Ca' -•tt • , .f;
I hereby affirm that there is a construction lending agency for the
ht '� �'°
performance of the work for which this permit is issued(Sec.3097,
Civ.C.). PERMIT FEE (Sub-Total) p`j Q C"HANGE
PLAN CHECKING FEE
Lender's Name /3 131300—i3 €!31 o/ �'�1
PERMIT ISSUING FEE
Lender's Address / p3 e.i 1 ?°�)'�
I certify that I have read this application and state that the above
TOTAL FEE / �O• /ZJ 02
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 f nsp c'on purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE ,
9-3 -91
Signatur f Permittee Date