HomeMy Public PortalAbout5802, 5808-10ALESSANDRO AVE_Electrical WORKERS COMPENSATION DECLARATION CE 806G ( Q) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
FOR APPLICANT TO FILL IN JOB nn�
Policy No Company EACH NO FEE ADDRESS 01- DI's
New Residential Bldgs & Pools
'0 Certified copy is hereby furnished 1 &2 Family Sq Ft $ — $ LOCALITY
Multi family Sq Ft — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department / Q�� Residential Swimming Pools OWNER OR
Date_4;;* Applicant �`�JtA4 641LOMS Outlets Rec51ght- Sw � FIRM NAMEMAIL
First 20
ADDRESS D 2A-D
CERTIFICATE OF EXEMPTION FROM WORKERS Total No _� Additional CITY Tel No
INSURANCE1-g7-lens—
COMPENSATION }
PLAN CHECK d
(This section need not be completed if the work involvedPLICANT O
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS U
Total No Additional cc
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No
permit is issued I shall not employ any person in any manner PERMIT (�
so as to become subject to the Workers Compensation Laws Range_ Heater_D W APPLICANT A44,wvgali.,PcIES W
Oven _ Dryer_W M ADDRESS
13 Top
uj G�aVE fn
Date Applicant Top FAU W H �j
Hood _ Fan Other_ CITY �'Q(/�/(� Tel No d
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE OR �y 1 r
Exemption you should become subject to the Workers REG NUMBER L3 J Class r/
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCfjSSED BY
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVAR
deemed revoked
Up to 1 Incl FINAL
OF
Over 1 to 10 InclDATE VALIDATION
/+ 7
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl r `
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL _
9 (commencing with Section 7000 of Division 3 of the Busi BY
( B ) Over 100 /
ness and Professions Code and my license is in full force and
effect Services
I Q—/ 0 200 Amp 'Under 600 V
License Numberat�.�3��•5 Lic Class 201 1000 Amp Under 600 V
Contractor /ka &AW Date Z Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that, I am exempt from the Contractors Sign with One Branch Circuit _
License,Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code) _
Misc Conduits&Conductors ;264 4,4 A
El I as owner of the property will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section # 0 0 0 • o 2
7044 Business and Professions Code) " 4
f
CONSTRUCTION LENDING AGENCY 2 0 - 3190
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is o 0 0 3 1 9 0=
issued (Sec 3097 Civ C) PERMIT FEE (Sub Total) 0
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) 0924-82
Lender s Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
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 inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
2 )7L r
Signature of Permittee to