HomeMy Public PortalAbout6033ALESSANDRO AVE_Electrical (2) WORKER S COMPENSATION DECLARATION 20 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT
76A663
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
PoliQ
ADDRESS
Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE
❑� I _ $ $ LOCALITY
Certified co is filed with the count building inspection 1 &2 Family Sq Ft
PY Y 9 P _ NEAREST
department Multifamily Sq Ft CROSS ST
Y t Residential Swimming Pools ASSESSOR
Date Applicant MAP BOOK
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERSOutlets Rec _Light E
Sw OWN NAMO
* COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by the MAIL n,
permit is for one hundred dollars(5100)or less) Total No Additional ADDRESS V
I certify that In the performance of the work for which this permit CITY �vA�
Tel No _ I
Is issued I shall not employ any person in any manner so as to PLAN CHECK /
become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPLICANT Z®�
_N Total No Additional
Date i 49 Applicant "�l� RESIDENTIAL APPLIANCES NOT OVER 3 HP ADDRESS
NOTICE TO APPLICANT If after making this Certificate of Ilk, CITY Tel No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP 292 179
provisions of the Labor Code you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances APPLICANT
'_ LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS �y
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl
(commencing with Section 7000) of Division 3 of the Business and CITY Tel No
Professions Code and my license is in full force and effect Over 10 to 50 Incl }
Over 50 to 100 Incl LICENSE B Class
��....�/����-�---�����////// A REG NUMBER �'7� O
Z-2 Over 100 DISTRICT NO P CESSED BY
License Number Lic Class U
/�//�`1.,, /,� Services Swbd MCC&Panelboards FINAL � � �+�-L.�
Contractor / "5 / 144Z✓Date 0 399 Amp Under 600 V DATE Q O
El
400 1000 Amp Under 600 V r —/� VALIDATION V
I am exempt under Sec U.1
Over 1000 Amp or Over 600 V FINAL IZ
B&P C for this reason BRANCH CIRCUIT FEES By
Date 15A or 20A 120V Lighting or Recept Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
F141 Or More Branch Circuits
Exemption for Reg Maint Elect 15A 20A 208V To 277V Lighting Br Circuits 2
SINGLE FAMILY Temp Power Pole&Appurtenances �5,('/' a
HOME OWNER BUILDER DECLARATION ACCToF
I hereby affirm that I am exempt from the Contractors License Law Sign with One Branch Circuit . �y -_15.75
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits f 1 7
Code) 1 ITENE'
❑ I as owner of the property will do the work and the structure Misc Conduits&Conductors
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) TOTAL 39 .. 7 -e
and Professions Code) CHECK 3�.7�
CONSTRUCTION LENDING AGENCY r i��wC�''
I hereby affirm that there Is a construction lending agency for the CH4NGE Oct
performance of the work for which this permit is issued (Sec 3097 PERMIT FEE (Sub Total)
Civ C)
PLAN CHECKING FEE �j(](]�t—dpi _/?4/93
Lender s Name
PERMIT ISSUING FEE 8857 1 PM
12'.2..
Lender s Address - - -4
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above information is correct I agree to comply with all County
ordinances and State laws regulating Elec ical wiring and hereby authorize
representat of this County to ent r u n the above mentioned property
for in tion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG ATURE OF PERMITTEE DATE