HomeMy Public PortalAbout5946ALESSANDRO AVE_Electrical Fir L
(WORKERS COMPENSATION DECLARATION 200019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT 0
I hP bylpffirm that I have a certificate of consent to self CEAg G
ensure OV a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or a certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB 59 ,0
OCertified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS 5 946 M kILMAN D RO AVC-.
Certified copy is filed with the county building inspec 1 & 2 Family Scl Ft $ — $ LOCALITY EMPtC-_ CITY
tion department Multi family Scl FtNEAREST
Residential Swimming Pools CROSS ST WOOD RV FrF
Date Applicant FWNER OR
IRM N ME w fUl AM V 916 HL Wem p
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw _ MAIL P X 6006
COMPENSATION INSURANCE ADDRESS G
First 20
1 I(This section need not be completed if the work Involved by Total No Additional CITY SAN �DIF-GOZ.tQbTel No�.2-<)8O 9
the permit is for one hundred dollars ($100)or less ) PLAN CHECK
4 1 certify that in he performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
G so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS _
yid � Additional
Date -t I Vy Applicant li " /{� Total No CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption you should become subject to the Workers Range— Heater DW — APPLICATION
44
Compensation provisions of the Labor Code you must forth Oven — Dryer iZ W M — ADDRESS
with comply with such provisions or this permit shall be Top -'— FAU —W H —
deemed revoked Hood , /Fan —Other_ CITY Tel No 1
LICENSED CONTRACTORS DECLARATION Disp Room Air Cond — LICENSE OR 1 Class \
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO / PROCES BY
and Professions Code and my license is in full force and effect Ol/
Size&Type HP KW KVA or KVAR r �
License Number Lic Class Up to 1 Incl FINAL U
Contractor Date Over 1 to 10 Incl DATE -� - VALI N cc
Over 10 to 50 Incl FINAL O
I am exempt under Sec Over 50 to 100 IncgY U
Over 100 ,� W
B &P C for this reason t1
Services Swbd MCC& Ponelboards U)
Date 0 200 Amp Under 600 V q Z
Signature 201 1000 Amp Under 600V
EJO%er 1000 Amp or Over 600 V
Exemption for Reg Mamt Elect 9 A
SINGLE FAMILY
Temp Power Pole &Appurtenances ( o 0 3 2 5
HOME OWNER BUILDER DECLARATION o e
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits f o 0 0 7j Z 5 p v
Professions Code)
® Misc Conduits&Conductors ( 1 1 1 0 8 8 I as owner of the property will do the work and the �
structure is not intended or offered for sale(Section 7044 Other (See Complete Fee Schedule)—
Business and Professions Code)
J
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 s
Lender s Name
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE 5,16
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 _
Signature of Permittee Date O: