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HomeMy Public PortalAbout6042ALESSANDRO AVE_Electrical WORKERS COMPENSATION DECLARATION CE 86 6G (2 80) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have,, a certificate of consent to self COUNTY OF LOS ANGELES G BUILDING AND SAFETY insure or a certificate of Workers Compensation Insurance or 1 / u a certified copy thereof(Sec 3800 Lab C) - ' FOR APPLICANT TO FILL IN SOB �© Q Policy No Company ADDRESS New,Residential Bldgs &Pools EACH NO FEE ❑ Certified copy is hereby furnished 1 &2 Family Sq Ft $ — $ LOCALITY a L Multi family Sq Ft — NEAREST Certified copy is filed with the county building inspection CROSS ST 40-4-94 department Residential Swimming Pools OWNER OR FIRM NA Eofall I t 7 F.- Date Applicant Outlets Rec,dLight Sw aO MAIL j __1First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY L Tel No.,> } COMPENSATION INSURANCE t PLAN CHECK tl PPLICANT / ( (This section need not be completed if the work involved _ U by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS L S Additional s fr Total No I certify that in the performance of the work for which this Fixed Applian7esNot Over 1 HP CITY 75iTel No permit is issued I shall not employ any person in any manner PERMIT . W so as to become subject to the Workers Compensation Laws Range_ Heater_D W APPLICANT a Oven _ Dryer_L W M � ADDRESS N Date_��Applicant Top _ FAU, _W H l - Z Hood _ Fan , —Other— -6 o i ,NOTICE TO APPLICANT If after making this Certificate of Disp Room Air Cond-2- 54 LICENSE�OR Exemption REG NUMBER Class p you should become subject to the Workers Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCE ED BY with comply with i such provisions or this permit shall be deemed revoked Size&Type HP KW KVA or KVAR Q Up to 1 Incl Over 1 to 10 Incl FINAL LICENSED CONTRACTORS DECLARATION } r DATE '9 �® „� VALIDATION Over 10 to 50 Incl FINAL �. I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc BY F FI 9 (commencing with Section 7000) of Division 3 of the Busi Over 100 4 --\ness and Professions Code and my license is in full force and effect Services 0 200 Amp Under 600 V License Number Lic Class 201 1000 Amp Under 600 V Contractor Date Over 1000 Amp or Over 600 V HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit 9 O 6 5 2 AAdditional Sign Branch Circuits >j License Law for the following reason (Section 7031 5 Busi # 0 0 0 0 0 2 ness and Professions Code) Misc Conduits&Conductors I as owner of the property will do the work and the Other (See Complete Fee Schedule)— l i structure is not intended or offered for sale (Section 2 0,0 6 2 2 v 7044 Business and Professions Code) r ` CONSTRUCTION LENDING AGENCY � � 0 0 0 6 2 2x5'0 I hereby affirm that there is a construction lending agency ' for the performance of the work for which this permit is PERMIT FEET (Sub Total) �! ( ��" y 0 4'2 Qi—8(J issued (Sec 3097 Civ C) Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) Lender s Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE 1 Z-, 2 above information is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring and f hereby authorize representatives of this County to enter upon the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date