HomeMy Public PortalAbout5832ALESSANDRO AVE_Electrical WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I heveby affirm that I have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LCIS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOBADDRESS �I 1
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE LOCALITY
❑ Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft. — $ $
PY Y 9 P _ NEAREST
department. Multi-family Sq. Ft. CROSS ST.
Residential Swimming Pools ASSESSOR
Date Applicant MAP BOOK
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR
COMPENSATION INSURANCE Outlets:Rec._Light Sov. FIRM NAME — Mp L 4
First 20 MAIL
(This section need not be completed if the work involved by the Total No. Additional ADDRESS �� S
permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this permit CITY KfPLT-_ Cly Q&)"
(P-El)a860
is issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT
.Total No. Additional
ADDRESS
Date 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
P p Y
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. LICE }
SE OR
Over 50 to 100 Incl. REGNNUM ER Class. d
Over 100 DISTRICT NO. P O SSED BY O
License Number Lic.Class/ U
Services,Swb ,MCC WI bo r
FINAL
Contractor Date / 0- m .Under XO 9 DATE
El I am exempt under Sec. 400-1000 Amp,Under 600 V ) 0Over 1000 Amp.or Over 600 V FINAL VALIDATION d
B.&P.C.for this reason BRANCH CIRCUIT FEES RY41 U)
Date: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 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
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit : ' •'
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits '
Code): "
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d
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Conus Conductors
I, as owner of the property,will do the work and the structure Misc.
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) „ 4s
and Professions Code).
ti-V _45
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 (Sec. 3097, PERMIT FEE (Sub-Total)
Civ.C.)
PLAN CHECKING FEE
Lender's Name / i_f ':j.,t =`_)I )�i I'T
PERMIT ISSUING FEE
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
represen of this County to er upon the above-mentioned property
for ection urpose SEE REVERSE FOR EXPLANATORY LANGUAGE
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�F PA MITTEE I DATE