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HomeMy Public PortalAbout5827ALESSANDRO AVE_Electrical WORKERS'COMPENSATION DECLARATION cDPW s,s7 76A66APPLICATION FOR ELECTRICAL PERMIT I h�eby affirm that I have a certificate of consent to self CE 806G insure; or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB o -f T�S��D d M,�� Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 5a Z/ LG7 iCY /� r Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY tion department. Multi-family Sq. Ft. NEARESTn Residential Swimming Pools CROSS ST. L�S 7uN�s D/` Date Applicant OWNER OR //77 FIRM NAME GXOP61F� L 1A 1J GI CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec light Sw._ MAIL q �� , COMPENSATION INSURANCE First 20 ADDRESS Gia 7`I / (This section need not be completed if the work involved by Total No. Additional CITY 7z-M e./T Tel. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit 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 t Total No. CITY Tel. No. Date � Z � Applicant Z��" 01 N. NOTICE TO APPLICANT: If, after making this Certifica of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATIONi Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 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 LICENSE OR I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. REG. NUMBER Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO. PROCESSED BY >_ and Professions Code, and my license is in full force and effect. 11- Size Size &Type HP, KW, KVA, or KVAR �1 ��� Q License Number Lic. ClassC Up to 1 Incl. FINAL � Contractor Date Over 1 to 10 Incl. JBY TE 9J/'� VALIDATION Over 10 to 50 Incl. NAL F- I am exempt under Sec. Over 50 to 100 Inc. Q B.&P.C. for this reason Over 10041yd Date: Ssea; Z eryjc s, Svy�d., MCC_ nelboard6 Z W2(h�'Ac'm`p. n er Vsr✓b Signature 201 - 1000 Amp. Under 600 V Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances �- Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor's license Sig Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): rz= TTP-MCI I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale Section 7044, Other (See Complete Fee Schedule)— r, Business and Professions Code). `I "� S. _� i.-• CONSTRUCTION LENDING AGENCY -HEC"� 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.). PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE 7?yt- t } 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 4the abov - ped pr perty for inspection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE iiinature ermittee Date ©s