HomeMy Public PortalAbout5802, 5808-10ALESSANDRO AVE_Electrical (2) COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT,
t I have a cer�fieotrrf consent to self CE 8066
aj;? Workers Compensation Insurance COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
thereof (Sec 3800 Lab C ) -
Company t FOR APPLICANT TO FILL IN JOB
PCertified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS L(r
❑ 1 & 2 Family S Ft�� $ _ $ LOCALITY L
Certified copy is filed with the county building inspec Y q
tion department Multi family Sq Ft CROSS NEAREST
Residential Swimming ools
Date Applicant WNER OR
FFIIRM NAME Ti e \
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw_ MAIL
COMPENSATION INSURANCE ADDRESS /
Tis section neenot be completed if the work involved b First 20
( hd p Y Total No Additional CITY Tel No
the permit is for one hundred dollars ($100)or less )
I certifythat in the performance of the work for which this - v PLAN CHECK
p IN
permit is issued I shall not employ any person in any manner i
so as to become subject to the Workers Compe sation Laws Lighting Fixtures First 20 ADDRESS
r Total No � Additional CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTIC I T If after n thi ertificat of APPLICANT
Exemption you should becom subject to the Workers Range_ Heater_D W —
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M — ADDRESS
41,
with comply with such provisions or this permit shall be Top — FAU —W H —
deemed revoked Hood Fan _Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENS OR /
I hereby affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond REG NUMBER Class G-/0-
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PRO SSED BY
and Professions Code and my license is in full force and effect Power Apparatus & Large Appliances D > >-
- CL
Size &Type HP KW KVA or KVAR �' / O
License Number Lic Class-,Ie�— Up to 1 Incl FINAL V
Over 1 to 10 Incl DATE V DATION OC
Contractor1e Over 10 to 50 Incl FIN O
F-1I am exempt under Sec V
Over 50 to 100 Inc B W
d
B &P C for this reason Over 100
Date+ Services Swbd MCC& Panelboards
1 0 200 Amp Under 600 VPoo. ;21 1 1 5 A
Signature 201 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V # o 0 o o • 'Z
or
Exemptio Reg Maint Eject
I
i° - 82,50
SINGLE FAMILY
Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit e • 0 8 2 5 0
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and 1 26-84
Professions Code) 1
❑ I as owner of the property will do the work and the G Misc Conduits &Conductors _ 1
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY -
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE `(Sub Total)
(Sec 3097 Civ C ) r
PLAN CHECKING FEE to
Lender s Name
' PERMIT ISSUING FEE 2 d r
Lender s Address
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 men tio I property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
V,111ure of Pe iWiO` (ratrt -
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1 1 i