HomeMy Public PortalAbout4835 AGNES AVE_Electrical_4/25/1979 OVORKERS' COMPENSATION DECLARATION CE BO6G 10/81 APPLICATION FOR ELECTRICAL PERMIT
I e,_ eYwn'that I have a certificate of consent to self
insure,tir a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No' Company FOR APPLICANT TO FILL IN JOB �� v
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
❑ LOCALITY sa t
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $
tion department. Multi-family Sq. Ft. NEAREST
Residential Swimming.Pools CROSS ST.
OWNER OR
Date Applicant p FIRM NAM
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec M Light �e Sw.� l� �/'� MAIL
COMPENSATION INSURANCE First 20 ADDRESS %A F--
(This section need not be completed if the work involved by Total No-3 L` Additional s CIT Tel. No �$
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 Fixture First 20 ADDRESS
v Total No. Additional
CITY Tel. No.
Date lolikki Applicant Fixed Appliances Not Over 1 HP PERMIT e
NOTICE O PLICANT: If, after making this Certifi of APPLICANT T
Exemption, you should become subject to the Workers' Range_ Heater—D.W.
-D-Qg Xl"
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer W.M._ ADDRES y�-
with comply with such provisions or this permit shall be Top _LFAU W.H. — 4r8
_
deemed revoked. Hood Fan _ Other_ CITY-1-t �` Tel. N .
LICENSED CONTRACTORS DECLARATION LICENSE OR nlpj
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROC ED Y
and Professions Code,and my license is in full force and effect.
Size &Type HP, KW, KVA, or KVAR' O
License Number Lic. Class Up to 1 Incl. FINAL V
Over 1 to 10 Incl. DATE ✓ VA ATION 09
Contractor Date❑ Over 10 to 50 Incl.
I am exempt under Sec. Over 50 to 100 Inc. BY BY Lu
ZA CL
B.&P.C. for this reason Over 100
Services, Swbd., MCC & Panelboards
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V -9 9 0 1.4 A
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. # 0 0 0 — 2
SINGLE FAMILY Temp. Power Pole & Appurtenances I o o63, 00
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License 6 O O x
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits o 0 0
Professions Code):
I, as owner of the property, will do the work and the Misc. Conduits & Conductors Q 222-88
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
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.).
LPLAN CHECKING FEE
Lender's Name N
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
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 p operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'�
Signature of Permittee Dat