HomeMy Public PortalAbout6033ALESSANDRO AVE_Electrical (3) WORKER S COMPENSATION DECLARATION 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)
i
Policy NO Company FOR APPLICANT TO FILL IN i JOB �� w /
Certified co is furnished t NO EACH FEE ADDRESS V
PY Y New Residential Bldgs &Pools _ $ $ LOCALITY' �� 4- CIZZ q�7l�v
❑ Certified copy Is filed with the county building Inspection 1 &2 Family Sq Ft
ARv
department Multifamily Sq Ft CROSSSST
Date` Applicant Residential Swimming Pools —. _ r ASSESSOR �� p�
'k t 9 MAP BOOK O PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec �liLl ht�S. �(� p OWNER OR Q
COMPENSATION INSURANCE OU Fi�� FIRM NAME
(This section needInot be completed if the work involved by the First 20 MAIL 1 ,/
permit Is for one hundred dollars($100)or less)
Total NO Additional 7ADDRESS O /_ cl.,
I certify that In tk1e performance of the work for which this permit CITY �a��� G Tel No '
Is Issued I shall not employ any �7 �Sperson In any manner so as to
become subject to the Workers Compensation Laws Lighting Fixtures First 20 PLAN CHECK
1 P 9 � APPLICANT r
Total No — Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If after makln t Is 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
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances APPLICANT
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
(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 _ }
LICENSE M
Over 50 to 100 Incl REG NUMBER Class
(� ��� Over 100 DISTRICT NO R SSED BY
License Number Llc Class p U
Services Swbd/tel C&P nelboar �o �
Contra Date Sr J t—c` _/ 0 399 i U� � F NAL DATE O
E] I am exempt under SecI� 400 1000 Amp Under 600V I f`— � VALIDATION W
Over 1000 Amp or Over 600 V FINAL d
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
❑ 41 Or More Branch Circuits
Exemption for Reg Maint Elect 15A 20A 208V To 277V Lighting Br Circuits f
SINGLE FAMILY Temp Power Pole&Appurtenances 7 7 g
HOME OWNER BUILDER DECLARATION ryC� i na
I hereby affirm that I am exempt from the Contractors License Law Sign with One Branch Circuit ^ �l-_
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits = 41r 1. �a
Code) 1 i IImot,�
I as owner of the property will do the work and the structure
❑ Misc Conduits&Conductors �i
Is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) Tt ITI-i{„ 139 - 05
and Professions Code)
t tHE{r; 0?e JC,
CONSTRUCTION LENDING AGENCY t ��� � Il
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
Lender s Name `
PERMIT ISSUING FEE p1;6y9 1 401:�-r
Lender sAddress �
TOTAL FEE IS
9 a
I certify that I have read this application and under penalty of purlury state
that the above Information Is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring and hereby authorize
representatives of this County to enter upon the above mentioned property
for Inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
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SIG OF PERMITTEE DATE