HomeMy Public PortalAbout5931ALESSANDRO AVE_Electrical (2) WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby 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 LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOBy ADDRESS ��
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. $ EACH $ FEE ADDRESS �-
❑ 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 esidential Swimming Pools ASSESSOR
MAP PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light�Sw.. p FOI P,M NAWNER OR
COMPENSATION INSURANCE First 20 i pQ
(This section need not be completed if the work involved by the AooRESS
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 CIT 2477
Tel.NoB�—
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 Y 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. LICENSE OR
Over 50 to 100 Incl. REG.NUMBER Class. d
Over 100 DISTRICT NO. PR OC SSED BY 0
License Number Lia Class Lfd—y'�Zf
Services,Swbd.,MCC&Panelbo<y�sf cc
Contractor Date /CO~. ? �
V 7 DATE r�FINAL O
400-1000 Amp. Under 600 V ~
❑ I am exempt under Sec.
VALIDATION U
Over 1000 Amp.or Over 600 V FINAL LU
B.&P.C.for this reason BRANCH CIRCUIT FEES BY
W
Date: 15A,or 20A, 120V, Light' or Rece Z
1 To ranch rcuits
Signature 11 To 40 Branch Chr6uits
El
41 Or More Branch Circuits
Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&Appurtenances s _
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I 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) T,7L 3"Zi.
and Professions Code). s cm
INE
CONSTRUCTION LENDING AGENCY t_` t_
I hereby affirm that there is a construction lending agency for the C•I t-€jifh okf3 S
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) _
Civ. C.)
PLAN CHECKING FEE j (�("—_f, i j
Lender's Name 3j �}L — —
PERMIT ISSUING FEE ! AM 8--1
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 ,
representatives of this County to enter upon the above-mentioned property
for i ecti,jurposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIGNATURE OF RMI E le, � It E 93