HomeMy Public PortalAbout5827ALESSANDRO AVE_Electrical (2) WORKERS'COMPENSATION DECLARATION 76- to/St APPL6�AT�ON FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE-806G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab. C.) fl
Policy No. - Company FOR APPLICANT TO FILL IN JOB
.1 1Certified copy is hereby furnished. New Residential Bldgs. & Pools
EACH NO. FEE ADDRESS 567-7 LE 5
$Ft $ LOCALITY
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2- amy, q. . —
Certified copy is filed with the county building inspection 1 & —
NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR yy�� //• ��
FIRM NAME
'CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light — Sw. — MAIL y. LFSS�AID,pQ �
COMPENSATION INSURANCE. First 20 ADDRESS
[,p� CJ? a G 1245
(This section need not be completed if the work.involved by the Total No. Additional CITY ( (�L Tel.No.a r0
permit is for one hundred dollars($100) or less.) PLAN CHECK
1 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_ HeaterD.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. Q CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other
I hereby affirm that I am licensed under provisions of Chapter 9 �i/ r LICENSE OR
(commencingDisp. — Room Air Cond.with Section 7000) of Division 3 of the Business and REG.NUMBER Class.
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. PR ED BY
Size& Type HP,KW,KVA;or KVAR �� 0
License Number Lic.Class Up to 1 Incl. FINAL 0
Over 1 to 10 Incl. DATE X
Contractor Date VALIDATION 0
Over 10 to 50 Incl. U
❑
I am exempt under Sec. Over 50 to 100 Inc. FINAL
W
0-
B.&P.C.for this reason Over 100 N
Services, Swbd.,MCC&Panelboards- ® Z
Date: 0- 200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole & Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit p_1•:.•
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits
for the following reason (Section 7031.5, Business and Professions
Code): _f_r` .40
Misc.Conduits& Conductors -
I,as owner of the property,will do the work and the structure _ YDIMS,
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) ® _ _
and Professions Code). !l-` i")'— 29_ -�
• CONSTRUCTION LENDING AGENCY CHECK
I hereby affirm that there is a construction lending agency.for the
performance of the work for which this permit is issued(Sec.3097,' PERMIT FEE (Sub-Total) U1H� I -1-
Civ.C.).
PLAN CHECKING FEE
Lender's Name // Ci 014.40_1010-)%
PERMIT ISSUING FEE /
Lender's Address 1 ti 1 i -T
1 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 regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
property f ection pur oses. SEE REVERSE FOR EXPLANATORY LANGUAGE
�o
Si ature Date