HomeMy Public PortalAbout6029ALESSANDRO AVE_Electrical (2) t
WORKERS COMPENSATION DECLARATION 76AM3 10/81
hereby 'affirm that I have a certificate of consent to self CE 806G APPLICATION FOR ELECTRICAL PERMIT
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certifjgd copy_th f (Sec 3800 L C )
Policy /�F d"Company O' FOR APPLICANT TO FILL IN JOB 1 a D _ /�
❑ Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE 11 ADDRES t ` 1/02q �J (7
(� 1 & 2 Family S Ft
$ = $ LOCALITY r`
Ju Certified copy is filed with t county building fflspec Y q
tion department Multi family Sq Ft CROSS NEAREST t\ f I i
Residential SwimmingPools
Date - Applican OWNER OR 20
FIRM NAME A V
CERTIFICATE OF EXEMPTION FR?M ZORKIJS � MAIL
Outlets Rec Light Sw_ [ 1
COMPENSATION INSURANCE Z 'ADDRESS da 0
is secompleted if the work involved b First 20
(Thsection need not be com p Y I Total No Additional CITY � Tel No -
the permit is for one hundred dollars($100)or less )
P
I certify that in the performance of the work for which this PLCHECK
ICANT
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 ADDR SSS
Total No Additional `
CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICANT r ! LL 0,
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 — le
deemed revoked Hood Fan _ Other_ CITY �! Tel No� L
LICENSED CONTRACTORS DECLARATION LICENS OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Cl V CI ss
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCESSE BY f
_and Professions Code and my license is in full force cl effect Power Apparatus& Large Appliances d
L Size &Type HP KW KVA or KVAR O
License Nu )r Lic Class Up to 1 Incl FINAL �} U
J -2 L( Over 1 to 10 Incl DATE VALIDATION VALIDATION Q
Contract r Date Over 10 to 50 Incl !
FINAL ~
❑ I am exemp under Sec Over 50 to 100 Inc BY t d
B &P C for this reason Over 100 j W
Date Services Swbd MCC& Panelboards
0 200 Amp Under 600 V /
Signature 201 1000 Amp Under 600V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect
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
Law for the following reason (Section 7031 5 Business and , :2 1 5 7 1 A
Professions Code)
❑ Misc Conduits & Conductors # o a 0 o o 2
I as owner of the property will do the work and the ,
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ® 2,- 0 1 3 5 0
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 10 0 0 1 3 5 0 x
I hereby affirm that there is a construction lending agency for 0529-84
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) 3
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name V
PERMIT`ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
3, s6
above information is correct I agree to comply with all County
ordi ces and State laws regulating Electrical wiring and
he authorize representatives of this County to enter upon '
t ove m < 1 p pert fo inspection purposes-79t 4� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signatur of Permittee Date