HomeMy Public PortalAbout5936ALESSANDRO AVE_Electrical (2) WORKERS COMPENSATION DECLARATION CEA to/Bt APPLICATION FOR ELECTRICAL PERMIT a
I hereby affirm that I have a certificate of consent to self �
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C )
l
Policy No Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
1 8 2 Famil S Ft $ — $ LOCALITY C'
Certified copy is filed with the county building inspec Y q
tion department Multi family Sq Ft — NEAREST O�
Residential Swimming Pools CROSSST
OR 1
Date Applicant FIRM NAME ( LV LQ
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec_Light Sw_ MAIL f
COMPENSATION INSURANCE First 20 ADDRESS Ij 1e$y
(This section need not be completed if the work involved by Total No Additional CITY Tel No at/
the permit is for one hundred dollars ($100)or less) PLAN CHECK V I I certify that in the performance of the work for which this APPLICANT jc+ t _-,J,_ee
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS 6 615-25,01.yLde-p
Total No Additional
Date Applicant CITY Le `� Tel Noagb- oy
Fixed Appliances Not Over 1 HP PERMIT I
NOTICE TO APPLICANT If after making this Cer ficaI
APPLICANT
DIU Exemption you should become subject to the WoRange_ Heater-DW —
Compensat on provisions of the Labor Code you must Oven _ Dryer W M — ADDRESS Q es�j,4✓Ld�with comply with such provisions or this permit shaTop FAU_ —W H
deemed revoked Hood _ Fan _Other_ CITY Q J Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROLE ED BY >,
and Professions Code and my license is in full force and effect G
V IL
Size &Type HP KW KVA or KVAR J O O
License Number Lic Class Up to 1 InclV
FINAL
Over 1 to 10 Incl DATE , VALIDATION Q
Contractor Date
E:1Over 10 to 50 Incl FINAL U
I am exempt under Sec Over 50 to 100 Inc BY
B&P C for this reason - Over 100
Services Swbd MCC& Panelboards —
Date 0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
DOver 1000 Amp or Over 600 V
Exemption for Reg Maint Elect _
SINGLE FAMILY Temp Power Pole& Appurtenances
HOME OWNER BUILDER DECLARATION o
Sign with One Branch Circuit a 9 3 U,5
I hereby affirm that I`am exempt from the Contractor s License o 0
Law for a following reason (Section 7031 5 Business and Additional Sign Branch Circuits a,,o
2 5
Prof ons Code)
I as owner of the property will do the work and the Misc Conduits&Conductors o o ro 2 5 5 0 E
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , 0302-84
7044 Business 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 PERMIT FEE (Sub Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE o _ )
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-a
ordinances and State jaws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
t ove m boned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
3a
Signature of Permittee Date