HomeMy Public PortalAbout6003ALESSANDRO AVE_Electrical 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 JOB
ADDRESS 6QQ3 1. - Ste, IA
Certified co s hereby furnished. NO. EACH FEE
PY Y New Residential Bldgs.&Pools _ $ $ LOCALITY 'T.0
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq. Ft. _ NEAREST
department. Multi-family Sq. Ft. CROSS ST. a
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. �IP,M NAME
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by the MAIL n
permit is for one hundred dollars($100)or less.)
Total No. Additional ADDRESS jpy, e �1,�
I certify that in the performance of the wor or which this permit CITY Tel.No.
is issued, I shall not employ any perso In ny manner so as to PLAN CHECK
become subject to the Workers' Comp atio Law Lighting Fixtures First 20 APPLICANT
Total No. Additional
ADDRESS
Date Applica 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. Power 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. �j
(commencing with Section 7000) of Division 3 of the Business and CITYZi T SE OR d C/16L Tel.No. ��f3
Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. LICE ��c'�
Over 50 to 100 Incl. REGNNUM ER pC S�/ ClassCl.Y/il >"
S'E a-
/1 �V fS Over 100 DISTRICT NO. PROD BY 0
License Numb Lic.Class l"
Sice erywbd.,MCC&Panelboards "F LeC.v cc
Contract rate — 10 0-399 Amp.Under 600 V FINAL 0
DATE
❑ I am exempt under Sec. 400-1000 Amp. Under 600 V f�
Over 1000 Amp.or Over 600 V FINAL c VALIDATION W
B.&P.C.for this reason BRANCH CIRCUIT FEES BY U)
Date: 15A,or 20A, 120V,Lighting or Recept. Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
EJ
41 Or More Branch Circuits _
Exemption for Reg. Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits 1.
SINGLE FAMILY Temp.Power Pole&Appurtenances �f` ..
HOME OWNER-BUILDER DECLARATION NOCT'
I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit . . .....
for the fallowing reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits -`30 6_3°J'
Code): ,_,r}}v:
-1
❑ I,as owner of the property, will do the work and the structure Misc.Conduits&Conductors v, a
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) TOTAL 63 - 45
and Professions Code). ® CASH 6.:;.4 ;
CONSTRUCTION LENDING AGENCY - CHANGE z 3 pf 1
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.) _
PLAN CHECKING FEE ;_I%Iii l—00 1 (%1_r/;3_
Lender's Name a
t�7
PERMIT ISSUING FEE - `1 i AM 7Q`4
`_
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. 1 agree to comply with all County
ordinance and State laws regulating Electrical wiring,and hereby authorize
at
this Cou to enter upon the above-mentioned property
SEE REVERSE FOR EXPLANATORY LANGUAGE
TTEE DATE