HomeMy Public PortalAbout5816ALESSANDRO AVE_Electrical WORKER'S COMPENSATION DECLARA:JON 20-0019 DPW(12-91)
" 76A663 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure,
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof.(Sec.3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS
E-1 /
Certified copy is hereby fyrnished. New Residential Bldgs.&Pools NO. EACH FEE
_
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. $ $ LOCALITY
_ NEAREST
department. Multi-family Sq.Ft. CROSS ST.
ury
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
WNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Req. Light First 20 S 20 FFIIRM NAME �} L�Pr�14
COMPENSATION INSURANCE
n i
(This section need not be completed it the work involved by the MAIL
permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS 25 /2a
I certify that in the performance of the work for which this permit CITY '-4— �� Tel.No. A 7"12
is issued, I shall not employ any person in any manner so as to PLAN
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
K
Total No. Additional
40-77773S
� Cy�,fs�� ADDRESS
Date i—_d l 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 of the Labor Code you must forthwith comply with Such PERMIT
provisions or this permit shall be deemed revoked.
Power Apparatus&Large Appliances APPLICANT
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. >_Over 50 t0 100 Incl. LICENSE Cl
REG.NUMBB ER ass. Q.
Over 100 DISTRICT NO. PROCE 0
License Number Lic.Class `� C)
Services,Swbd.,MCC&Panelboards .J• 1 cc
Contractor Date 1010 0-399 Amp. Under 600 V O DATE FINAL 0
❑ I am exempt under Sec. 400-1000 Amp.Under 600 V �` LU
Over 1000 Am or Over 600 V VALIDATION
P FINAL �
B.&P.C.for this reason BRANCH CIRCUIT FEES /� BY
Date: 15A,or 20A, 120V,Lig ti q�I,- z
1 T/TPlt) IG1 s
Signature it �r • Its
❑ 41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION "' a
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit 3 `�•�.•1 n v
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits
KO'';� ' "jcfa 55
Code):
I, as owner of the property,will do the work and the structure
Misc.Conduits&Conductors 3•E L tv`=
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ;
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the CHs:NGEE
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total)
Civ. C.)
PLAN CHECKING FEET )9.^p-;�r
Lender's Name 1
PERMIT ISSUING FEE M;;i;i pfxt
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 in pec'on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG ATURE OF PERMITTEE DATE