HomeMy Public PortalAbout5936ALESSANDRO AVE_Electrical WORKERS COMPENSATION DECLARATION 1CE863 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE 8066
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C )
Policy No v Company FOR APPLICANT TO FILL IN JOB u l
Certified co is hereby furnished EACH- NO FEE ADDRESS �� ►3'"
PY Y New Residential Bldgs 8 Pools
VKV-
Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ _ $ LOCALITY &-1,,,0 6 C
tion deportment Multi family Sq Ft NEAREST , /
Residential Swimming Pools CROSS ST liCil
Date Applicant OWNER OR _ � 1 � e J
�y
/ FIRM NAME /w v �
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec___—Light -Z Sw 3 MAIL
COMPENSATION INSURANCEADDRESS f�
� First 20
(This section need not be completed if the work involved by Total No Additional CITY T—e_n I. 4-7 Tel No
the permit is for one hundred dollars($100)or less ) 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 Com ensatio Laws Lighting Fixtures First 20 ADDRESS
Total No Additional
,�t� � CITY � Tel No
_e
Date — Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICANT
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 — r�
deemed revoked Hood — Fan _Other_ CITY Tel No %e"�[
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp — Room Air Cond REG NUMBER CI` J `-' Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PR ED BY
and Professions Code and my license is in full force and effect , d
Size &Type HP KW KVA or KVAR Q
License Number Lic Class C 1 t!J Up to 1 Incl FINAL tJ
Contractor I �L7ate `^� z-' Over 1 to 10 Incl �INT� �r VALIDATION U
Over 10 to 50 Incl r
I am exempt under Sec Over 50 to 100 Inc BY WL
Over 100
B 8P C for this reason Z
Services Swbd MCC& Ponelboards ►
Date 0 200 Amp Under 600 V
1
Signature 201 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Eject
SINGLE FAMILY Temp Power Pole& Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits
Low for the following reason (Section 7031 5 Business and ' 1 0 J 4 A
Professions Code) \ i
I as owner of the property will do the work and the Misc Conduits&Conductors # 0 0 0 0 0 2
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044 Business and Professions Code) Pool 2 0 0 1950
CONSTRUCTION LENDING AGENCY o o 1 9 5 0 H
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE i (Sub Total) 0 507 -,84
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County 1 ,
ordinances and State laws regulating Electrical wiring and
_ hereby authorize representatives of this County to enter upon
the above me tione �fortion purposes
JC` SEE REVERSE FOR EXPLANATORY LANGUAGE
r �
Signature of Permittee Date