HomeMy Public PortalAbout4901 AGNES AVE_Electrical__ WORK ERSI�COMPENSATION DECLARATION -663 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMIT
.r he2¢eby affirm that I hale cent''' ate o; consent to self insure, CE
or a certificate of &rkers;-Comps n frlsurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sed.'3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS 4901 N. Agnes Ave.
❑ 1 & 2-Family, Sq.Ft. $ — $ LOCALITY Te le Cit Ca
Certified copy is filed with the county building inspection
department. Multi-family Sq.Ft. — NEAREST
CROSS ST. Lowe Azusa
Date Applicant
Residential Swimming Pools OWNER OR
Kim NAME YOun K.
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—3— Light Sw. MAIL
COMPENSATION INSURANCE ADDRESS S3Tft@
This section need not be completed if the work involved b the First 20
( p y Total No. 6 Additional CITY Temple Cit Tel.No. 286-00$
permit is for one hundred dollars($100)or less.)
I certifythat in the performance of t e ork for which this permit PLAN CHECK SC'm@
P A APPLICANT
is issued, I shall not employ any pe o in any manner so as to
become subject to the Workers'Come satin ws. Lighting Fixtures First 20 ADDRESS
p Total No.—1� Additional CITY Tel.No.
Date 6�3�87 Applic nt Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, f r making this Certificate of PERMIT same
Exemption,you should become s ect to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top — FAU _ W.H.
CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR
Disp. — Room Air Cond. REG.NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. t PROCESSg6 BY a
Size& Type HP, KW,KVA,or KVAR L ® (� Q
License Number Lic.Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl. DATE VAL -TION 0:
Contractor Date Over 10 to 50 Incl. U
❑ I am exempt under Sec. Over 50 to 100 Inc. FNA 'BY fid
B.&P.C.for this reason Over 100 N'
Services,Swbd., MCC & Panelboards ;2 7 1 5.7 A Z
Date: 0-200 Amp.Under 600 V
Signature 201 - 1000 Amp. Under 600 V # 0 0 0 0 0 'Z
❑
Exemption for Reg.Maint.Elect. Over 1000 Amp. or Over 600 V I c - 1 5 7 5
SINGLE FAMILY Temp.Power Pole& Appurtenances o.° ° 1 5 7 5=
U
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits 0603-87
Code):
® Misc.Conduits & Conductors
I,as owner of the property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other (See Complete Fee Schedule) ►
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(Sec.3097, PERMIT FEE (Sub-Total) S
Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certif t t I have read this application and state that the above TOTAL FEE
infor i its correct. I agree to comply with all County ordinances
and laws regulating Electrical wiring, and hereby authorize
repre tatives f t is County to enter upon the above-mentioned
prop r or in n purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
nun K, Kim 6/3/87
Signature of Permittee Date