HomeMy Public PortalAbout5754ALESSANDRO AVE_Electrical (3) � t
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Wm that S COMPENSATION DECLARATION CE 806 ,D/e, APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure CE a06G
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C) c
Policy NO Company FOR APPLICANT TO FILL IN t „JOB �+
❑ Certi copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS �] J
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Certified co y g 1 & 2'Family Sq Ft $ — $ LOCALITY '
copy is filed with the count building inspection
department ) Multi family Sq Ft M1 — CROSSSST
T .etc
Date � Applicant �C �[r/1Vbr��7 Residential Swimming Pools -t fir ) ` ' ` OWNER OR n
FIRM NAME , h a
CERTIFICATE OF EXEMPTION FROM WORKERSOutlets Rec Light� Sw " MAIL
— , , a
COMPENSATION INSURANCE' First
+, w 0 ADDRESS
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(This section need not be completed If the work involved by the First 20 CITY - Tel No
permit Is for one hundred dollars($100)or less) Total No Additional y
+ PLAN CHECK
I certify that in the performance of the work for which this permit f APPLICANT ;
ais 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
l� Total No � Additional CITY" Tel No '
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of
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;Exemption you should become subject to the Workers Compensation Range_ Heater_ DW _ APPLICANT
dprovisions of the Labor Code you must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS1
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orovisions or this permit shall be deemed revoked Top _ FAU ! WH
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY Tel No
I Thereby affirm,that I am hcensed�under provisions of Chapter 9Disp — Room Air Cond + LICEN Class t
(commencing with Section 7000) of Division 3 of the Business and REG NUMBER
Pi,ofessions Code and my license is in full force and effect Power Apparatus& Large Appliances ; DISTRICT NO PROCESSE Y ;
Size & Type HP KW KVA or KVAR
O
License Number � ) Lic ClassUpUp to 1 Incl FINAL / U
Contractor V Date C> Over 1 to 101Incl DATE „ O
!/ VALIDATION
❑ Over 10 to 50 Incl FIN
I am exempt under Sec Over 50 to 100 Inc W
B&P C for this reason Over 100 4
Services Swbd MCC & Panelboards Z
Date 0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
µ Over 1000 Amp or Over 600 V µ
❑ Exemption for Reg Maint Elect
SINGLE FAMILY Temp Power Pole & Appurtenances 8 8 2 A
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractors License Law # 2
for the following reason (Section,7031 5 Business and Professions Additional Sign Branch Circuits - 0 0 0 0 0
Code)
❑ '
I as owner of the property will do the work and the structure Misc Conduits& Conductors o 0d1 a7 5
is not intended or offered for sale (Section 7044 Business Other (See Complete Fee Schedule) Poo. _ o o el a 7 5 5i
and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there Is a construction I Wiling agency for the
performance of the work for which'this perm is issued(Sec 3097 PERMIT FEE i ° (Sub Total)
Civ C)
A
' PLAN CHECKING FEE I T
Lenders Name
PERMIT ISSUING FEE
Lenders Address
I certify that I have read this a hcatr and state that the above TOTAL FEE
information is correct 1 agree comply with all County ordinances
and State laws regulating Elettrical wiring and hereby authorize
" representatives oft s County to enter upon the above mentioned +
pro ty for in �
pe(?71n purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
2
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Signature of Permittee Date
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