HomeMy Public PortalAbout4847 3/8, 4853 AGNES AVE_Electrical_11/14/1989_new addition 2700 sq ft VWORKERS COMPENSATION DECLARATION20 S DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT
.,,.--byE 8066 affirm that I have a certificate of consent to self C or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or a certified copy thereof(Sec 3800 Lab C )
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Policy No Company FOR APPLICANT TO FILL IN JOB 140
❑Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS 0 �S
❑Certified copy is filed with the county building mspec s 1 &2 Family'Sq Ft0— $ — $ J Z LOCALITY �-
' tion department Multi family Sq Ft NEAREST
Date Applicant Residential Swimming Pools CROSS OWNEROR +
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light First Sw_ MAIL �A
r COMPENSATION INSURANCE 20 ADDRESS O3 !-I
(This sectionfneed not be completed if the work involved by CITY
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I certify that in the performance of the work for which this PLAN CHECK
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permit is issued I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers Compensation La s
c p Additional
Date 1-6-a Applicant /� Total No CITY Tel No
NOTICE TO APPLICANT If after making is Certificate of Fixed Appliances Not Over 1 HP PERMIT { / �—
Exemption you should become subject to the Workers Range— Heater—D W — APPLICATION
Compensation provisions of the Labor Code you must forth Oven — Dryer —W M — ADDRESS D
with)comply with such provisions or this permit shall be _
deemed revoked Hood —"Fan —Other— CITY 65 Vf Tel No 33432
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp _ Room Air Cond —
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER I/ /3 Class 6_0
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DIST C NO PRSSED BY
and Professions Code and my license is in full force and effect D_
Size&Type HP KW KVA or KVAR Q
License Number 'y`� 713� Lic Class G�� Up to 1 Incl FINAL V
Contractor adte� Over 1 to 10 Incl DATE VALIDATION 0
❑ Over 10 to 50 Incl FINAL
I am exempt under Sec Over 50 to 100 Inc BY W
B&P C for this reason Over 100 D_
Date Services Swbd MCC& Panelboards ► Z
0 200 Amp Under 600 V —
Signature 201 1000 Amp Under 600V
❑ Exemption for Reg Mainf Elect O%er 1000 Amp or Over 600 V
SINGLE FAMILY Temp Power Pole 8 A
HOME OWNER BUILDER DECLARATION Appurtenances
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit
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Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits L
Professions Code) 3307 118.9r,
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❑ I as owner of the property will do the work and the Misc Conduits&Conductors VITEMS
structure is not intended or offered for sale(Section 7044 Other (See Complete Fee Schedule)_
Business and Professions Code) t TOTAL
118.030
CONSTRUCTION LENDING AGENCYHECY, 118s�1]
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) CHANGE sail
(Sec 3097 Civ C '
PLAN CHECKING FEE � AGO-0001 11I14l�t:9
Lender s Name _ ti
PERMIT ISSUING FEE _ 6795 1 PM12"51
Lender s Address ti .
I certify that I have read this application and state that the I 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
the ab vgme one prop rty for inspection purposes "
SEE REVERSE FOR EXPLANATORY LANGUAGE
LI�Vlei 5
Signature of ermittee Date ®s