HomeMy Public PortalAbout4840 AGNES AVE_Electrical_9/30/1959 s WORKERS COMPENSATION DECLARATION 200019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT Q
I
hereby affirm that I hav'd a certificate of consent folself CE806G
'insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
n or a certified copy thereof (Sec 3800 Lab C ) r
Policy No r Company FOR APPLICANT TO FILL IN JOB
❑Certified copy is hereby furnished New Residential Bldgs &Pools EACH NO FEE ADDRESS 1"+i�OI"+ss
t $ _ $ LOCALITY 1,� C
rfified copy is filed with ih county ildi g inspec 1 &2 Family Sq Ft 77
NEAREST
tion depart ent Multi family Sq Ft CROSS ST G4.A
Date Applicant Residential Swimming Pools OWNER OR
t��
r FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw_ MAIL
COMPENSATION INSURANCE First ADDRESS
CITY
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(This section need not be completed if the work involved by `i Total No Additional 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 1� IrntJS
permit is issued I shall not employ any person in any manner Lighting Fixtures First 20 s ADDRESS
so as to become subject to the Workers Compensation Laws
Additional
` Total No CITY� Tel No
Date Applicant ` Fixed Appliances Not Over 1 HP PERMIT i
NOTICE TO APPLICANT-If after m"aking this Certificate of � APPLICATION b1CdE c ,4-4Lr.P
Exemption you should become subject to the Workers Range— Heater—D W
Compensation provisions of the Labor Code you must forth Oven — Dryer —W M — ADDRESS V 1
with comply with such provisions or this permit shall be Top — FAU —W H —
deemed revoked , Hood — Fan —Other_ CITY T1�7tU Tel Nol(-15110
LICENSED CONTRACTORS DECLARATION LICENSE OR
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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 PR SED BY d
and Professions Code and my license is in full force and effect p✓�
Size 8 Type HP KW KVA or KVAR U
License Number Lic Class Up to 1 Incl FINAL `
Over 1 to 10 Incl DATE VALIDATION 0
Contractor Date ` O-ver 10 to 50 incl FINAL r U
❑ I am exempt under Sec Over 50 to 100 Inc BYUJI
B 8P C for this reason
Over 100 CL
' Services Swbd MCC&Panelboards b Z
Date 0 200 Amp Under 600 V (PV
Signature 201 1000 Amp Under 600 V
ED
ver 1000 Amp or Over 600 V 1 '�
Exemption for Reg Maint Elect
SINGLE FAMILY 2
t Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATION a
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuli HCCT.t
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits Jir e�
Professions Code) I I
❑ I as owner of the property will do the work and the Misc Conduits&Conductors 1 ITEMS 1
structure is not intended or offered for sale(Section 7044 Other(See Complete Fee Schedule)_ , TOTAL 17®c50
Business and Professions Code) CHECK 17.cu
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 ) '
PLAN CHECK%ING FEE
Lender`Name
PERMIT ISSUING FEE 6
Lenders Address t
I certify that I have read this application and state that the I TOTAL FEE
above information is correct I agree to comply with all County r ^
or nces and St jaws regulating Electrical wiring and
h re authon a re esentatrves of this County to enter upon
fh a ve a ho d property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE I
501
Signature of Permittee /1'- ®s
Date
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