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HomeMy Public PortalAbout5833ALESSANDRO AVE_Electrical (2) WORKERS' COMPENSATION DECLARATION 76A663 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE-806G insure, o.a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or,o"certified copy thereof (Sec. 3800, Lab. C.). Policy No. Company FOR APPLICANT TO FILL IN JOB ❑ pCertified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS �0 33 to35CLJO Ave., '% El'Certified.copy is filed with the county building inspec- 1.& 2-Family, Sq. Ft. $ — $ LOCALITY tion department. Multi-family Sq. Ft. NEAREST jjll__ Residential Swimming Pools CROSS ST. ! � 7UJtC(.S Date Applicant p .0 OWNER OR J l Yr l FIRM NAME IlChO q CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL Outlets: Rec Li ht Sw. QS � COMPENSATION INSURANCE g -"7e Oa ADDRESS �''l ��, First 20 I' p (This section need not be completed if the work involved by Total No. Additional r lP t� CITY C Tel. N ��J •-�9/f the permit is for one hundred dollars ($100)or less.) .oG 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 f�C First 20 ADDRESS Additional Total No. CITY Tel. No. Dote Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION r..! Exemption, you should become subject to the Workers' Range— Heater—D.W. 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. CITY Tel. No. LICENSED CONTRACTORS DECLARATION Hood — Fan Other Disp. _ Room Air Cond. 3 DO LICENSE M Class. I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER (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. 0- Size Size &Type HP, KW, KVA, or KVAR O License Number Lic. Class Up to 1 Incl. FINAL U Contractor Date Over 1 to 10 Incl. DATE g VALIDATION cc Over 10 to 50 Incl. FINAL O ❑ I am exempt under Sec. Over 50 to 100 Inc. gy U W B.&P.C. for this reason Over 100 W Services, Swbd., MCC & Panelboards ZZ 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 HOME OWNER-BUILDER DECLARATION Temp. Power Pole 8 Appurtenances Sign with One Branch Circuit Vit•: I hereby affirm that I am exempt from the Contractor's License f+x•t:1 .,s LVas r'the following reason (Section 7031.5, Business and Additional Sign Branch Circuits ;;'_`� ions Code): of=i Misc. Conduits& Conductors IT ' owner of the property, will do the work and the z -I °f', structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ � 17 o a0 Business and Professions Code). CONSTRUCTION LENDING AGENCY ' +'ISI` `=' I hereby affirm that there is a construction lending agency for O I_)iH;q_i 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 O 3 D •_rs3 i #Lz i Lender's Address 7 H. -z I certify that I have read this application and state that the TOTAL FEE OrA 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 pro ert -perpposes SEE REVERSE FOR EXPLANATORY LANGUAGE ©s ignature of Permittee/ Date