HomeMy Public PortalAbout6056ALESSANDRO AVE_Electrical (2) WORKERS' COMPENSATION DECLARA,?ION 76A663 10:81 `APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C. ` A
Policy NoSC]�l� rompany�T�.�� �«�` FOR APPLICANT TO FILL IN JOB
Certified co s hereby furnished. EACH NO. FEE ADDRESS
PY Y New Residential Bldgs. & Pools
S — `E
' Certified copy is filed with the county building inspec- 1 & 2-Family, 9� Ft. $ $ LOCALITY rT—
tion department. Multi-family Sq. Ft. NEAREST
\_ CROSS ST. ��
Date\2—\(rsR�npplicant �`� -��n Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec l!3--Li hgt '2_ S
_ w .� MAIL
COMPENSATION INSURANCE r, e First 20 f'7� 1/0 1 Z' ADDRESS !2, �
(This section need not be completed if the work involved by Total No. Additional CIT ' Tel No. -\_ �I.R
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
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. Ix Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of (a�
Exemption, you should become subject to the Workers' Range APPLICANT
Heater D.W.
Compensati� 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. CITY Tel. No.
deemed revoked. Hood Fan Other \
LICENSED CONTRACTORS DECLARATION aj LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. • REG. NUMBER q Class. Q�1-:
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances ` + Q-
Size &Type HP, KW, KVA, or KVAR' Ji O Q� v'�� 0
License Number i _qZZ_ S!kLic. Class Up to 1 Incl. FINAL
lffOver 1 to 10'Incl.' DATE ,,. -.� VALIDATION
Contractor
❑ ` - Over 10 to 50 Incl FINAL LJ
I am exempt under Sec. Over 50 to 100 Inc. BY 126
44
B.&P.C. for this reason Over 100
Services, Swbd. +&�panelb�oa�rds
Date: n-Amp. Under 60 V _�
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power.Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION 7 6 5 3 A
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits ti: c o o o 2
Professions Code): 2 0 1, 6700
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ , 1 n o r O 7, 0 0 X
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY t,
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 to
Lender's Address
I certify that I.have read this application and state that the TOTAL FEE 6
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
Signature at Permittee Date