HomeMy Public PortalAbout5801ALESSANDRO AVE_Electrical WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that 1 have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensatiori Insurance, or a certified . COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof'(Sec.3800 Lab. C.)
FOR APPLICANT TO FILL IN ,,{{)
Policy No. Company ADDRESS AlzP L1 L-c�vw z,,
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE$ $ LOCALITY
F11 &2-Family,Sq.Ft. ��, C�•� L� - / 7
_Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq. Ft. CROSS ST. S / kICFH"S
Date Applicant Residential Swimming Pools ASSESSOR
PP ' MAP BOOK PAGES PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec.L Light Sw. OWNER OR NAME �? ,''rv�/� G/e.
COMPENSATION INSURANCE FIRM
(� First 20 MAIL
(This section need not be completed if the work involved by the Total No. Additional ADDRESS ,j i?v A -
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY Tel.Nq7 3 3 F(p
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. � Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP.
provisions or this permit shall be deemed revoked.s of the Labor Code, you must forthwith comply with such PERMIT
provisions
p Py Power Apparatus&Large Appliances APPLICANTGL�ryLIe��
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY Tel.No.
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. LICENSE OR
Over 50 to 100 Incl. REG.NUMBER Class. a
Over 100 DISTRICT NO. PROCE D By O
License Number Lic.Class ``rr" ()
Services,Swbd.,MCC&Panelboards -FINAL V d
Contractor Date 0-399 Amp.Under 600 V �' DATE 0
❑ 400-1000 Amp.Under 600 V
I am exempt under Sec. VALIDATION L
Over 1000 Amp.or Over 600 V FINAL
B.&P.C.for this reason BRANCH CIRCUIT FEES By d
Date: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits - - , n
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 'L3 : 1__°,° �i
SINGLE FAMILY Temp.Power Pole&Appurtenances a. i•TL"I:t
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit _
I hereby affirm that I am exempt from the Contractor's License Law ,r"• •ti-_
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits ; a - "n "
Code): "f -
❑ I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors _ 4.H=
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code).
..
-7? 6/95 Irl
CONSTRUCTION LENDING AGENCY -.'•I. 0 ?`(..lig-:_ i
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) G/� 66
Civ. C.)
PLAN CHECKING FEE
Lender's Name /-
PERMIT ISSUING FEE 4"6�
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the 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 the above-mentioned property
for insp ction purpos t SEE REVERSE FOR EXPLANATORY LANGUAGE
of
SIGN RE OF RMITTEE DATE