HomeMy Public PortalAbout4851 AGNES AVE_Electrical_11/14/1989 y • ° r
♦ WORKERS COMPENSATION DECLARATION 76AB63 10/81 Tn
I hereby affirm that I have a certificate of consent to self insure CE 806G APPLICATION FOR ELECTRICAL PERMIT
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy t re (Sec 3800 C) "
POIIC O Company FOR APPLICANT TO FILL IN " ," JOB
ra ;
rtified co is hereby furnished a EACH NO FEE ADDRESS
PY Y r New Residential Bidgs &Pools
ST
t "1 &2 Family Sq Ft $ . ( $ �' ' LOCALITY L"
rtified copy is fled,with the my budding inspection + .+ _ _ _ j° NEAREST
// p rtm t Multi family Sq Ft
C.� A cant Residential Swimming Pools r CROSS 0 ,
OWNER OR
FIRM NAME �.
°
CERTIFICATE OF*EXEMPTION FROM WORKE+RS MAIL
I Outlets Rec—Light_Sw —
COMPENSATION INSURANCEADDRESS I +
+ T" First 20
r (This section need not be completed if the work Involved by the s >
permit Is for one hundred dollars($100)orFess) Total No Additional " y CITY Tel NZsZi
5 ry
I certify that,in the performance of the work for which this permit , PLAN CHECK
to an APPLICANT
is issued I shall not employ y y person In any manner so as to ,
become subject to the Workers Compensation Laws Lighting Fixtures ° First 20 ADDRESS
Additional
T Total No CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP r PERMITe `
NOTICE TO APPLICANT If after making this Certificate of APPUCANrl
Exemption you should become subjec�to the Workers Compensation Range_ Heater_ DW _ '
provisions of the Labor Code you must forthwith comply with such Oven ' Dryer N W M _ ADDRESS
provisions or this permit'shall be deemed revoked Top FAU _ WH _
,
yLICENSED CONTRACTORS DECLHood Fan Other_
ARATION ' -CITY + Tel No
+
I hereby' affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond r LICENSE ORr Class r
(commencing with Section 7000) of Division 3 of the Business and REG NUMBER
Professions Code and my license Is in full force and effect DISTRICT NO PROCESSED BY
Power Apparatus&Large Appliances O
} " r
Size&Type HP KW KVA or KVAR `
License Number LC
Class - Up to 1 Incl f FINAL 00,
r ,, Over 1 to 10 Incl DATE ��Z
Contracto — } dte VALIDATION
❑ "'Over 10 to 50 Incl +
FINA
I am exempt under Sec Over 50 to 100 Inc BY , t W
r B&P C for this reason + Over 100
Services Swbd MCC&Panelboards _ Z
Date " 0 200 Amp Under 600 V
+ Signature ` 201 1000 Amp Under 600 V
El _ Over 1000 Amp or Over 600 V + I
Exemption for Reg Maint Elect t M
4
Y � t
4 r SINGLE FAMILY r kAd
p Power Pole&Appurte nces ( r f2
HOME OWNER BUILDER DECLARATION with One Br iJL
I hereby affirm that I am exempt from the Contractors License Law itiona Sign Branch Circuits , IAGT..
for the following reason(Section 7031 5 Business and Professions _ �G
Code) ' f 3307 23.3]0
M
r❑ Misc Conduits&Conductors f ` s I as owner of the property will do the work and the structure I " s"{ 1 ITEMS
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) 25.50
and Professions Code) + TOTAL
9 = urt�V �f¢ en
CONSTRUCTION LENDING AGENCY I CHECK + Z5■57
1 hereby affirm that there is a construction lending agency for the 8
performance of the work for which this permit is issued(Sec 3097 LM PERMIT FEE , (Sub Total) �� ` CHANGE r r woo
Civ C)
Lenders Name PLAN CHECKING FEE
PERMIT ISSUING FEE , '/0 .� , :
36
Lenders Address '" S�y 5168" 1 X911••
I certify ter
e read this application and state that the above TOTAL FEE
rinformatioct I agree omply with all County ordinances
and Stategulati le ncal inng and hereby authorizerepresentsth oun to r upon the above mentio dproperty on Pur ses ' +
SEE REVERSE FOR EXPLANATORY LANGUAGE }
Sign re of Perm ltt Date