HomeMy Public PortalAbout6018ALESSANDRO AVE_Electrical WORKERS COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT
Ir hereby offrrm that I have a certificate of consent to self CE 8066
insur`e`'o a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
' Nr a g�rtiAed copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB
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Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS Iry
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Certified copy is filed with the county building inspec 1 & 2 Family9 Ft $ $ LOCALITY
tion department Multi family Sq Ft - NEAREST
/ CROSS ST
Residential Swimming Pools OWNER OR
Date Applicant g FIRM NAME
CERTIFICATE OF EXEMPTION FROMrWORKERS V (J '� r r �` MAIL
Outlets Rec Light Sw_ ADDRESS
COMPENSATION INSURANCEt SSS
is section neenot completed if the work involved b First 20
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P Y Total No Additional CITY-- �A4>��L�^[ Tel No
the permit is for one hundred dollars ($100) or less ) PLAN CHECK
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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
+
� Total No Additional` CITY No
Datevr ApplicantAkaa
at o Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If of king his CertificAPPLICANT
Exemption you should become subject to the Workers Range_ Heater D W
Compensation provisions of the Labor Code you must forth Oven _ Dryer T_W M T ADDRESS
with comply with such provisions or this permit shall be Top _ FAU W H CITY Tel No
deemed revoked Hood Fan _ Other_
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 D sp Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the BusinessPower Apparatus& Large Appliances 1 DISTRICT NO�-� ! PRO SSED BY
and Professions Code and m license is in full force and effect 1a( }
Size & Type HP KW KVA or KVAR O
License Number Lic Class Up to 1 Incl FINAL /� V //��/� U
° Over 1 to 10 Incl DATE '/ - -/ DLIDATION _ IM
Contractor Date❑ Over 10 to 50 Incl U FINAL
I am exempt under Sec Over 50 to 100 Inc BY d
B &P C for this reason Over 100 W
Services Swbd MCC & Panelboards Z
Date 0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600V
Over 1000 Amp or Over 600 V
Exemption for Reg Maint Eject
SINGLE FAMILY Temp Power Pole &Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit 8 9/1 U A
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and # o o e oro 2
NET
Code)
I T I as owner of the property will do the work and the Misc Conduits& Conductors ) m o 7000
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ® ° ° ° 7 fl a_
7044 Business and Professions Code)
_ CONSTRUCTION LENDING AGENCY 02 10-88 '
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
Lender s Address
I certify that I have read this application and state that the TOTAL FEE otV
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 ab�Zvhfigjj,
ned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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nater f ermitteeDate
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