HomeMy Public PortalAbout5750ALESSANDRO AVE_Electrical (3) WORKERS'COMPENSATION DECLARATION 76-663 10/$1 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insureCE-806G
or a)cerfific;to of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
cop` thereof(Sec.3800,Lab.C.
c WCGtoaga. D `n/ J
Policy NO. �Company 45 CA w7 P r i OV- �'aQA�( FOR APPLICANT TO FILL IN JOB
❑ •ertified copy is hereby furnished. Q New Residential Bldgs.& Pools EACH NO. FEE ADDRESS S a ev 4 U
Certified co 1 & 2-Family,Sq.Ft. $ — $ LOCALITY
copy is filed with the county building inspection
department. _
f
> Multi-family Sq. Ft. NEAREST CROSS ST.
•- /` �1 O L Residential Swimming Pools OWNER OR
Date Applicant �/ C S Q E $ ! FIRM NAME / " -3
CERTIFICATE OF EXEMPTION FROM WORKERS' / MAIL
Outlets:Rec— Light Sw. — I
COMPENSATION INSURANCE � ADDRESS 3�� S(7 � w CT• ✓-"o
(This section need not be completed if the work involved by the First 20.
permit is for one hundred dollars($100)or less.) Total No. Additional CITY P' e '� Tel.No.
I certify that in the performance.of the work for which this permit PLAN CHECK'
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 PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of f
Exemption,you should become subject'to the Workers'Compensation Range_ Heater_ D.W. APPLICANT Q rV e ^� S c,`e S N C
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M.= ADDRESS ` C vYl Pca C(
provisions or this permit shall be deemed revoked. Top _ FAU L W.H.
CITY r7
LICENSED CONTRACTORS DECLARATION Hood Fan Other_ j ('c S T L N .�`� _ f C(4;
I hereby affirm that I am licensed under provisions of.Chapter 9 Disp.'— Room Air Cond. LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER 5^/- Class. Z
Professions Code,and my license is in full force and effect. DISTRICT NO. PROCE BY
Power Apparatus& Large Appliances. a�
_ O Size& Type HP,KW,KVA,or KVAR .5
License Number f J 7- Z (o Lic.Class �T Q Up to 1 Incl. FINAL U.
C� G �� �G?♦/fSa�te V-�� Over 1 to 10 Incl. DATE VALIDATION Q
Contractor 'k
❑ Over 10 to 50 InclV
FINAL
1 am exempt under Sec. Over 50 to 100 Inc.
BY W
B.&P.C,for this reason Over 100 / N'
Services,Swbd.,MCC& Panelboards , 1 Z
Date: 0- 200 Amp.Under 600 V 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 2
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit q
I hereby affirm that I am exempt from the Contractor's License Law ACCT.a Ir
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits j
Code): s�0? �iAt
❑ ITEMS
I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors I
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL
and Professions Code). ' F'O f AL •22 .50
CHECK
22 =tf
CONSTRUCTION LENDING AGENCY - �•l11r.C•�t '.. a.a.a•��.r
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) CHANGE- °C0
Civ.C.).
PLAN CHECKING FEE
Lender's Name' OFJOO-7001 12/19/89
PERMIT ISSUING FEE 7623 1 AM10*c
Lender's Address i i 1 E
I certify that I have read this application and state that the above TOTAL FEE
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 inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE . . ,
Signature of Permittee Date