HomeMy Public PortalAbout4910 AGNES AVE_Electrical_0 r
WORKERS COMPENSATION DECLARATION 76
63 APPLICATION FOR ELECTRICAL PERMIT
'4 CE CE 8 806G (2 80) �
1 hereby alafirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or I
a certified copy thereof(Sec 3800 Lab C)
' � FOR APPLICANT TO FILL IN Mpg
Policy No 1 Company ' New Residential Bldgs &Pools EACH NO FEE ADDRESS
Certified copy is hereby furnished 1 &2 Family Sq Ft $ — $ LOCALITY
Aj
Multifamily Sq Ft NEAREST
Certified copy is filed with the county building inspection
department Residential Swimming P�jii CROSS STOWNER OR ^�'I' / /
FIRM NAME V W /�
Date Applicant Outlets Rec_Light Sw MAIL
First 20 ADDRESS `/1�0 14014-C 5 i
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional -7CITY .o Tel No
COMPENSATION INSURANCE C acli3
f PLANCHE �� �7 d
(This section need not be completed if the work involved APPLICANT I�r� Q //X
20
e
xt
F
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures FirstADDRESS l
Total No
Additional O
I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No
permit is issued I shall not employ any erson in any manner PERMIT
so as to become subject to the Worke Compensation Laws Range_ Heater DW _ APPLICANT Is tl
1 r �n�
Oven _ Dryer_W M ADDRESS
ate Applicant Top _ FAU _W H
°kamLe !
Hood _ Fan —Other— CITY � et No U�
NOTICE TO APPLICANT If iter making this Certificate of Disp _ Room Air Cond_ LICENSE OR r
_k?
Exemption you should bec me subject to the Workers REG NUMBER 3 Class C�
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO P S D BY
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVARd r
deemeevoked
Up to 1 Incl
Over 1 to 10 Incl - FINAL
DATE
LICENSED CONTRACTORS DECLARATION /£ s� VALIDATION
Over 10 to 50 Incl ® �j G
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
9 (commencing with Section 7000)of Division 3 of the Busi Over 100 BY `--- A
-ness and Professions Code and my license is in full force and
effect Services �jJQ
License Numberl�3 Y3 J Lic Class 6 S-3 0 200 Amp Under 600 V
201 1000 Amp Under 600 V V U y(O p y
``Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances -
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit,
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code)
Misc Conduits&Conductors
I as owner of the property will do the work and the
Other(See Complete Fee Schedule)—
;03822A
structure is not intended or offered for sale (Section # • • • • • 2
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency ' 2 •t• 2 8 J5 O
for the performance of the work for which this permit is PERMIT FEE (Sub Total) JJ'�
issued(Sec 3097 Civ C) V • • • 2 8 5 O
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) t 0 IL 2 8—8 2
Lender s Address PERMIT ISSUING FEE 6 r
t
I certify that I have read this application and state that the TOTAL FEE J(1
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring and
hereby authors "representatives of this County to enter upon ,
the above men o ed property forinspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ature of Permittee s� Dat
� � i