HomeMy Public PortalAbout5754ALESSANDRO AVE_Electrical (2) a ,
WORKERS COMPENSATION DECLARATION 10/81
CE 806G APPLICATION FOR ELECTRICAL PERMIT
CE 806
\T t hereby affirm that I have a certificate of consent to self insure I
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof (�c, � ' '
Policy /l��fl 6dl- ompany FOR APPLICANT TO FILL IN JOB c
Certified copy is hereby furnished EACH NO FEE ADDRESS S es- o
Y New Residential Bldgs & Pools
F-1 — $ LOCALITY
Certified copy is fled with the county bwldi inspection
1 & 2 Family Sq Ft $
departmer Multi family Sq Ft — NEAREST A Aj s
�C Residential Swimming Pools OWNER OR- CROSS /Mv
Date Applicant
f FIRM NAME 'S
CERTIFICATE OF EXEMPTION FROM WORKERS ra Outlets Rea Light Sw 3 MAIL C /
COMPENSATION INSURANCE e > ADDRESS
l First 20 s
(This section need not be completed if the work involved by the Total No ��� Additional b' S` L CITY 4 Tel No
permit Is for one hundred dollars($100)or less) ,Q _
K
I certify that in the performance of the work for which this permit " APPLICANT ba io 0
v
is issued I shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws s i Lighting Fixtures First 20 s ADDRESS s _ v s
I Additional CITY / Tel No
Total No � e ry'�1 3����
Date Applicant wFixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after (making this Certificate of' APPLICANT l
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW _
provisions of the Labor Code you must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS Lw S
provisions or this permit shall be deemed revoked ` + Top — FAU- _ WH ' CITY 6 T ice/ Tel No3762171 1
LICENSED CONTRACTORS DECLARATION, Hood — Fan _ Other_
I hereby+affirm that I am licensed under provisions of Chapter 9_,- Disp — Room Air Cond LICEt REGNNE OR Class 6�
(commencing with Section 7000) of Division 3 of the Business and
Professions Code and my license is in full force and effect Power Apparatus& Large Appliances DISTRICT NO PROCESSEQ BY
3 Size& Type HP KW KVA or KVAR , �! G
License Number ` Lic Class v / Up to 1 Incl ti FINAL 1� , + V
GoAj� �// A?�� � $� Over 1 to 10 Incl DATE /� / � V LIDATION 0
Contractor 1� C�.Y�jate �'" `�/ 5'
Over 10 to 50 Incl FINAL f F-^
❑ I am exempt under Sec Over 50 to 100 Inc
BY W
B&PC for this reason Over 100 2 8 6 3 2 A r N
k Services Swbd MCC& Panelboards Z
Date 0 200 Amp Under 600 V # o 0 0 0 0 2
Signature 201 1000 Amp Under 600 V 1 0 - 2400
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect
0 o 024005 ,
SINGLE FAMILY y Temp Power Pole& Appurtenances+ w
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit 1218-87
1 hereby affirm that I am exempt from the Contractors License Law
for the following`reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits
Code)
Misc Conduits & Conductors
ElI as owner of the property will do the work and the structure Other(See Complete Fee Schedule)
i is not intended or offered for sale (Section 7044 Business
and Professions Code)
CONSTRUCTION LENDING AGENCY s
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
Lenders Name 0
PERMIT ISSUING FEE t O
Lenders Address
I certify that I have read this application and state that the above TOTAL FEE r- -
information is correct I agree to comply with all County ordinances
and State laws regulating Electrical wiring and hereby authorize r
representatives of this County to enter upon the above mentioned
property for inspects urposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
a
Signature of Permittee Date