HomeMy Public PortalAbout6013ALESSANDRO AVE_Electrical WORKERS COMPENSATION DECLARATION CE 806Q 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of corsent to self
insure ora certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) /
Policy No Company FOR APPLICANT TO FILL IN JOB
F-1CertifiedCertified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS
❑ 1 & 2 Family S Ft $ — $ LOCALITY
Certified copy is filed with the county building inspec Y q
tion department Multi family Sq Ft — NEAREST 1
Residential Swimming Pools CROSS ST
Date Applicant OWNER M
j FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw MAIL
COMPENSATION INSURANCE J First 20 ADDRESS
(This section need not be completed if the work involved by Total No Additional CITY Tel No
the permit is for one hundred dollars ($100)or less ) i 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 Compensation Laws Lighting Fixtures First 20 ADDRESS
q / � %� � Total No Additional CITY - Tel No v
-4ate a 'a`'"P_&pplicanta "° _, _AgZm�1 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 —
deemed revoked Hood _ Fan _ Other_ CITY Tel No-
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm thattl 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 PROCESS BY
and Professions Code and my license is in full force and effect �� 0
- Size & Type HP KW KVA or KVAR
License Number Lic Class Up to 1 InclU
FINAL
09
Over 1 to 10 Incl DATE ��- r VALIDATION 0
Contractor Date Over 10 to 50 Incl FINAL V
❑ I am exempt under Sec Over 50 to 100 Inc BY
B &P C for this reason Over 100 h
Date
Services Swbd MCC& Panelboards , Z
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
❑
Exemption for Reg MaOver 1000 Amp or Over 600 V
mt Elect
t
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 4 6 5 9 A
Law for the following reason (Section 7031 5 Business and
Professions Code)
❑ I as owner of the property will do the work and the Misc Conduits& Conductors # c o 0 o o2
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)-
7044 Business and Professions Code) , 1 21° - 2 5150
CONSTRUCTION LENDING AGENCY fo o e 2 5 5 0 0
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) - 0 8,2 2—&3
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE 1
Lender s Address '
I certify that I have read this application and state thattthe TOTAL FEE /
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
the above mentioned property for inspection purposes
P r SEE REVERSE FOR EXPLANATORY LANGUAGE
J`Signature of Permittee Date