HomeMy Public PortalAbout4857 AGNES AVE_Electrical_10/24/1989 Ot -,-ORKERS'COMPENSATION DECLARATION 76-663 10/81 CE-806G APPLICATION FOR ELECTRICAL PERMIT
hereby af4fir�i that I have a certificate of consent to self insure,
r,a,Eiertif&p e sof,"trkers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
cof;y thereof (Sec. 3800,Lab C.) _
' t�� � 2�� FOR APPLICANT TO FILL IN JOB
Wolicy h..ti, ompany 4�
❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS
Certified copy is filed with,,the county building inspection .
1 & 2-Family,Sq.Ft. $ — $ LOCALITY
dep #ment. Multi-family Sq.Ft. NEARESTCROSS ST..
L® Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME j
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. — MAIL
COMPENSATION INSURANCE ADDRESS' G
(This section need not be completed if the work involved by the First 20
Total No. Additional CITY el.No^ �'2`�
permit is for one hundred dollars($100)or less.) 4t •
I certify that in the performance of the work for which this permit PLAN CHECK.APPLICANT APPLCANT
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
Additional
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: It, after making this Certificate of �r-
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top FAU _ W.H. _
LICENSED CONTRACTORS DECLARATION Hood Fan Other_ CITY Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE B r
(commencing with Section 7000]of Division 3,of the'Business and Disp. — Room Air Cond. REG.NUMBER `, - Class. J
Professions Code,and my license is in full force and effect. DISTRICT NO. PR SED Y
Power Apparatus& Large Appliances
( Size& Type HP, KW,KVA, or KVAR i o�
License Number / , d 1 L 1 Lio Class Up to 1 Incl. FINALQ-0 0
/ �• y� Over 1 to 10 Incl. DATEO0.
Contractor/��`.�— Date Cl ( VALIDATION 0.
❑ Over 10 to 50 Incl. FINAL I—
I am exempt under Sec. Over 50 to 100 Inc. BY LLJ
L)
B.&P.C. for this reason Over 100 N
Services,Swbd.,MCC & Panelboards
Date: 0- 200 Amp.Under 600 V
RIX e�
Signature 201 - 1000 Amp.Under 600 V
❑ Over 100 or Over 600 V _
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp,Power Pole& Appur 'nces �1 2
HOME OWNER-BUILDER DECLARATION Sign wd ne Branch Circuit Amt
ACC
I hereby affirm that I am exempt from the Contractor's License Law T®•V
for the following reason(Section 7031.5, Business and Professions. Additional Sign Branch Circuits 3^^ 2Sa5Cl
Code): 307 . ..
El1, Conduits& Conductors 1 ITEM
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) ®
and Professions Code). TOTAL 25- �-
.50
CONSTRUCTION LENDING AGENCY CHECK 25.50
1 hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, CHANGE
PERMIT FEE (Sub-Total) a[ I
Civ. C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE 0000—MOI 10/24/89
;' � i!
Lender's Address —�� 6376 1 AM10:36
I certify that I have read this application and state that the above TOTAL FEE '
information i orrec ee to comply with all County ordinances
and State a egulatin Elect ical wiring, and hereby authorize
represe ti sof this ount t enter upon the above-mentioned
prop r i ection urp f
SEE REVERSE FOR EXPLANATORY LANGUAGE
at of Per ittee Date —�