HomeMy Public PortalAbout4907 AGNES AVE_Electrical_6/9/1959 6*ORKERS COMPENSATION DECLARATION 76A&3 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE 8066 7�
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING A D SAFETY 'uI
or a certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB ADDRESS o Y
Certified copy is hereby furnished New Residential Bidgs 8 Pools EACH NO FEE
— $ ^
Certified copy is filed with the county building inspec 1 &2 Family Sq Ft $ LOCALITY
tion department Multifamily Scl Ft —
Residential Swimming Pools + CROSS ST N
OWNER OR
Date Applicant v AWbVPN"E
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light4.r.st
Sw_ / ADDRESS Vr
COMPENSATION INSURANCE 20
(This section need not be completed if the work involved by Total No Additional CITY Tel No
the permit is for one hundred dollars(;100)or less) PLAN CHECK
IF
I certify that in the performance of the work for which this * APPLICANT s
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 Additional
CITY � Tel N
Date Applicant , — ��s�cd��
NOTIC TO APPLICANT If of er making this Certificate of Fixed Appliances Not Over 1 HP APPLICANT
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
with comply with such provisions or this permit shall be Top _ FAU —W H
deemed revoked Hood _ Fan _Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION Disp Room Air Cond REG NUMBER
OR Class
I hereby affirm that I am licensed under provisions of Chapter 9
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO PR SED BY O.
and Professions Code and my license is in full force and effect Power At8 Large Appliances na�
0
Size&Type HP KW KVA or KVAR / 0
License Number Lic ClassFINAL tit
to 1 Incl
Over I to 10 Incl DATE �-�6 VALIDATION Ol'—
Contractor Date
Over 10 to 50 Incl FINAL P.1.1
I am exempt under Sec Over 50 to 100 Inc BY CL.
Over 100 Cn
B&P C for this reason Z_
Date Services Swbd MCC 8 Ponelboards
0 200 Amp Under 600 V _
Signature 201 1000 Amp Under 600 V
i
Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V �5 2 Q 4 A
SINGLE FAMILYI I - - 1 ,125
Temp Power Pole 8 Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit 1e • • 2 5i�
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits
Low for the following reason (Section 7031 5 Business and 0 a 18-g 6
Professions Code)
I as owner of the property will do the work and the Misc Conduits 8 Conductors r
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 )
PLAN CHECKING FEE
Lender s Name 1Z,
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 jaws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
the bove mentioned property for inspection purposes
�J��� m_/�� 4� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date �9