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HomeMy Public PortalAbout5937ALESSANDRO AVE_Electrical (3) WORKER'S COMPENSATION DECLARATION 20-0079 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I hereto affirm,that I have a certificate of consent to self insure, 76A663 or a Certificate 61 Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec. 3800 Lab. .) Policy No.(9 —q3 t srr Y�L( `�' l�lN� ` ComPan FOR APPLICANT TO FILL IN JOB F-1Certified Certified co .Is hereby furnished. NO. EACH FEE ` - PY Y New Residential Bldgs.&Pools $ $ LOCALITY 09 Certified co is filed with the count building inspection 1 &2-Family,Sq.Ft. PY Y g P NEAREST department. ® Multi-family Sq.Ft. CROSS ST. Date 15-1_1 !5 AAppI. ter ��A — ��E:/ Residential Swimming Pools ASSESSOR S MAP BOOK ��j PAGE PARCEL dam. CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec. Light _Sw. a OWNER OR COMPENSATION INSURANCE FIRM First 20 (This section need not be completed if the work involved by the MAIL permit is for one hundred dollars($100)or less.) Total No.� Additional ADDRESS %DQ I certify that in the performance of the work for which this permit CITY r�M Tel.No. is issued, I shall not employ any person in any manner so as to PLAN CHECK 14 become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT U0.� Total No. Additional 3 ADDRESS ..5-5 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 APPLICANT provisions or this permit shall be deemed revoked'. Fower Apparatus&Large Appliances , 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 r �� �, Tel.No.�TT©�� Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. } a Over 50 t0 100 Incl. LICENSE OR REG.NUMBER d Class. O P Over 100 DISTRICT NO. PROCESSED BY License Number L®qq ( Lic.Class V Services �SwbQd.J,�. CC&Pa elboards i FINAL � Contractor Date 't !T L 399 fo. r 600 V ` DATE / 7�A O ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V -) i\v VALIDATION W Over 1000 Amp.or Over 600 V FINAL � B.&P.C.for this reasonBRANCH CIRCUIT FEES BY Date: 15A,or 20A, 120V,Lighting or Recept. Z 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg. Maint. Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION Sigh 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): El 1,as owner of the property,will do the work and the structure Misc.Conduits&Conductors - �-C-7=50 3 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) , _ _ and Professions Code). _ !:t ID ..7; IX CONSTRUCTION LENDING AGENCY ).,tra-Kz7 -7Z_._ r,....:•�.,•�.� 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.) G ori PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE -A. :_ y Lender's Address `''( �'Y Iw `r 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 inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE :=!5x RE OF PERMITTEE DATE