HomeMy Public PortalAbout5823ALESSANDRO AVE_Electrical WORKERS'COMPENSATION DECLARATION 76-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
CE-806G vd�[1 E�9
I hereby affirm that I have a certificate of consent to self insure,
or a certifjcate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab. C.)
`Policy No.7$� � Company � FOR APPLICANT TO FILL IN JOB
EACH NO. FEE ADDRESS
Ceetified copy is hereby furnished. New Residential Bldgs. &Pools
R7} 1 & 2-Family, Sq.Ft. $ _ $ LOCALITY
L� Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft. �4
` CROSS O
Date �aM!% Applicant C`� eiG. Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' 2 �i MAIL
COMPENSATION INSURANCE Outlets:Rec Light Sw.
DDRESS
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars($100)or less.)
Total No. �� Additional CIT Tel.No.
PLAN CHECK rA
I certify that in the performance of the work for which this permit APPLICANT
is 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
Additional
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption,you should become subject to the Workers'Compensation Range— Heater— D.W. APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven — Dryer — W.M.— ADDRESS
provisions or this permit shall be,deemed revoked. Top — FAU — W.H. — CITY Tel:No
LICENSED CONTRACTORS DECLARATION Hood — Fan — Other—
I hereby affirm that I am licensed under provisions of Chapter 9Disp. — Room Air Cond. •— LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Class-Z—
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT O. PROC SSED BY
Size& Type HP,KW,KVA,or KVAR
I i
License Number��s�i`!� Lic.Class— Up to 1 Incl. FI NA At
Q,`�� Over 1 to 10 Incl. DATE /VALIDATION 0
Contract •� Date \ Over 10 to 50 Incl. FI V
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
Over 100 �-
B.&P.C.for this reason N
Services M nelboards �`
Date: CO- 200 Amp.Under 600 V
UV I
Signature 201 - 1000 Amp.Under 600 V S
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp:Power Pole & Appurtenances 37 40.50
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ITEMS
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits TOTAL Code): 1O TO4050
❑
I, n Other (See Complete Fee Schedule)Misc.Conduits& Conductors, CRECK 40.%
owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business � •••. ..- .. yy�
and Professions Code).
CONSTRUCTION LENDING AGENCY f7
I hereby affirm that there is a construction lending agency for the Qu =- 8/29/8,9
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) �A99 p p
Civ.C.). +J�3�d 1 AN $CM
PLAN,CHECKING FEE U
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances
and State laws re Electrical wiring, and hereby authorize �y
pre es of tl�s to enter upon the above-mentioned (/kJv
pert for ins e .
SEE REVERSE FOR EXPLANATORY LANGUAGE
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