HomeMy Public PortalAbout5128 AGNES AVE_Electrical_0 ` T WORKERS COMPENSATION DECLARATION 76A663CE806 10/81 r APPLICATION FOR, ELECTRICAL PERMIT z
I hereby affivlf's that I have a certificate of consent to self insure CE 8o6G
or atertikate of Workers Compensation Insurance or a certified R COUNTY OF,LOS ANGELES r BUILDING AND SAFETY
c0,py thereof(Sec 3800 Lab C)
Policy No ' ` Company ( f
� FOR APPLICANT TO FILL IN JOB C I
A❑ Certified copy is hereby furnished a 1 New Residential Bldgs & Pools EACH NO FEE ADDRESS 5125 I�C�JI,�ES {�(/�
R + $ (LOCALITY1 7- , 4
r� Certified copy,is filed 'with the county building inspection y 1 & 2 Family Sq Ft $ r
i w y, • NEAREST
department Multi family Sq Ft
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- CROSS ST
Date _ (Applicant a Residential Swimming Pools ��t * OWNER OR a ;
t <' {, 8 >; „r ti (FIRM NAME Q)I E,4, a
t k r2 b t
CERTIFICATE OF EXEMPTION FROM WORKERS `t ' ro°J '"'� �u { r
Outlets Rec Light Sw ' w
COMPENSATION INSURANCE { fip a ADDRESS + 7 moi` h
(This section need not beVcom leted if the work involved,by the r +" + First 20 �` f . " , 1 _
p z y � �",���'°'" o- c., CITY � r Tel No
Total No Additional �+ i �� .2%6-1772 s
permiteis for)one hundred dollars ($100)or less) , ,
c s ° t c �' l PLAN CHECK
I certify that in the performance'of the workrfor which this"permit a ' t ,
is issued'I shall not employ any person in any manner so as t�+ a ; ICANT
become subject to the Workers Compensation Laws r , Lighting Fixtures First 20 ` ADDRESS
��9 ti y _ ,, Additional x ' _ s
Date4 )(Applicant "DIL f�1 A L�e Total No r CITY Tel No f
Fixed A liances Not°Over 1 HP r
NOTICE TO APPLICANT If' after making this Certificate of PP o 1, PERMIT ry X
Exemption you should become subject to the Workers Compensation Range_ Heater= DW APPLICANT
provisions of the Labor Code you must forthwith comply with such Oven _ Dryer _~WM ADDRESS 4
provisions,or this permit shall be deemed revoked Top — FAU WH
- LICENSED CONTRACTORSiDECLARATION t Hood Fan l Other_ CITY Tel No ;
1 I hereby[affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond a v LICENSE OR ' Class y
(commencing with Section 7000) of Division 3 of the Business and r REG NUMBER
Professions Code and m license is in full`force and effect e DISTRIC O PROCESSED By
y Power Apparatus& Large Appliances
` Size& Type HP KW KVA or KVAR _ r v 4 ` Q
License Number Lic Class '
Up to 1 Incl. FINAL U
I '` 4 r + } s Over 1 to 10 Incl N f DAT •/ ''Q� VALIDATION Yn f Tr
C'ontracto'r n Date vv 0
Over 10 to 50 Incl F
a❑ lam exempt under Sec T ri Over 50 to 100 Inc y 9 2 Q 7 R 0
w r Over 100 O
w 1.1
B&PC for this reason 'r r , #
0 0 0 0 0 2 Z
Services Swbd MCC& Panelboards $ ,
Date 0' 200 Amp Under 600 V '
a
I, Signature r y ^� 201 ^1000 Amp Under 600 V r ( * " 1 - - 12,00
ar s + sOver 1000 Amp or Over 600 V '
m
❑ Exeption for Reg Maint'Elect w e e o o12005
=t SINGLE FAMILYK _ Temp Power Pole& Appurtenances 0 3 � 9-88
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit a '
'S I hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuits
for the following reason(Section 7031 5 Business and Professions +
Code) 9
I as owner of the propertyt•wdl do the work,and the structureA t Misc Conduits & Conductors a 3 ^
is not intended or offered for sale (Section 7044 Business ' Other (See Complete Fee Schedule) r
and Professions Code)
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'r CONSTRUCTION LENDING AGENCY
°1, I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec 3097 'PERMIT FEE, (Sub Total) °
Civ C) ; t r ; _ I
* tr ' S w z e
a` [ PLANaCHECKING,FEE ° 1
Lenders Name r v
' PERMIT ISSUING FEE
r Lenders Addressx + {
I certify that I have'read this'application and'state that the above' tiTOTAL FEE
information is correct I agree to comply with all County ordinances
`and State laws regulating Electrical wiring and hereby>authonze
representatives of this County"to enter`upon the above mentioned '
property for inspection purpose , ,
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of Permittee j Date
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