HomeMy Public PortalAbout5848ALESSANDRO AVE_Electrical (2) WORKER'S COMPENSATION DECLARATION 76A663 9 DPW 9/89 APPLICATION FOR ELECTRICAL PERMIT
76A66
I hereby affirm'that I have a certificate of consent to self insure, -
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab. C.)
Policy N /company_� FOR APPLICANT TO FILL IN JOB
ADDRESS
El Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. 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.
Date Applicant Residential Swimming Pools ASSESSOR
PAGE PARCEL
CERTIFICATE OF EXEMPT FROM WORKERS' Outlets:Rec.�Light Sw. / FlRMNER OR
NAME ,
COMPENSATION SURANCE First 20 D v �O /1
(This section need not be completed if the work involved by the ADDRESS Ci�if
permit is for one hundred dollars($100)or less.) Total No. Additional
I certify that in the performance of the work for which this permit CITY Tel.No.It l
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 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH
IT
provisions of the Labor Code, you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH
LICENSED CONTRACTORS DECLARATION ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH
(commencing with Section 7000) of Division 3 of the Business and CITYTel.No. `�..j , Y U
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO 3HP LICENSE OR i o a
Power Apparatus&Large Appliances. REG.NUMBER Class
License Number Lic.Class C-,/ Size&Type HP,KW,KVA,or KVAR DISTRICT NO. PR ED BY o
r U
Up to 3 Incl. LLI
d
Over 3 to 10 Incl. FINAL
Contractor,oDate v/ Over 10 to 50 Incl. DATE 1 i 0)
❑ 1 am exempt under Sec. Over 50 to 100 Incl. 1 VALIDATION
Over 10o FBY
INALB.&P.C.for this reasoner-��Jy/
. Services,Swbd.,MCC&Panelboards
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
1 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 --• - ' ' "
Code):
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). , *•
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 I_;.� '--•-•- �'=dj*''
Lender's Name _
PERMIT ISSUING FEE a1-/ 7
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 regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
property fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
SI RE Or APPLICANT OR AGENT DATE