HomeMy Public PortalAbout5112 AGNES AVE_Electrical_0 WORKERS COMPENSATION DECLARATION 63
CE 806G (2 801 APPLICATION FOR ELECTRICAL PERMIT
CE 8 /
I hereby affirm 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
a certified copy thereof(Sec 3800 Lab C)
FOR APPLICANT TO FILL IN SOB
Policy No Company New Residential Bldgs &Pools EACH NO FEE ADDRESS
Certified co is hereby furnished $ — $ LOCALITY
PY 1`&2 Family Sq Ft
❑ Certified co Y g inspection family Sq Ft NEAREST
copy is Bled with the count buildin ins ection S
department Residential Swimming Pools OWNER OR ;
FIRM NAME
Date Applicant Outlets Rec_Light Sw MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY Tel No �-
}
COMPENSATION INSURANCE e PLAN CHECK Il
O
This section need not be completed if the work involved Lighting Fixtures First 20 APPLICANT 1 U
igeng
y the permit is for one hundred dollars ($100) or less) ADDRESS
Total No Additional O
certify that in the performance of the work for which thisOHP CITY Tel No U
Fixed Appliances Not Over 1
Permit is issued I shall not employ any person in any manner PERMIT
so as to become subject to the Workers Compensation Laws Range_ Heater_D W APPLICANT d
Oven _ Dryer_W M t ADDRESS Z
Z
Date Applicant Top _ FAU _W H
Ur-
Hood _ Fan _Other_ CITY _
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE OR
Exemption you should become subject to the Workers REG NUMBER Class
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PRQCES&tD BY
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVAR O
deemed revoked Up to 1 Incl
FINAL
Over 1 to 10 Incl DATE // 101,
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl —` ( VALI DATION
I hereby iaffirm 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 •
ness and Professions Code and my license is in full force and
effect I Services
License Number Lic Class 0 200 Amp Under 600 V
201 1000 Amp Under 600 V
Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER 13UILDER DECLARATION Temp Power Pole&Appurtenances W I }
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
gi-il as owner of the property will do the work and the ;-93 � 9 9 A
Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044 Business and Professions Code) # 010 0 0 o 2
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency 2 0 - 205,0
for the performance of the work for which this permit is PERMIT FEE (Sub Total) - i
issued(Sec 3097 Civ C) 0 0 io 20 5 O v
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) 0 3 09-82
Lender s Address PERMIT ISSUING FEE
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 laws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon f
the v entioned property spection purgoses SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee ate