HomeMy Public PortalAbout4950 AGNES AVE_Electrical__ WORKERS COMPENSATION DECLARATION 76 63 APPLICATION FOR ELECTRICAL PERMIT
CE 806G (2 80)
I hereby affirm that I have a certificate of consent to self CE 8 COUNTY OF LOS ANGELES �]� BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or / ( r
a certified copy thereof(Sec 3800 Lab C)
FOR APPLICANT TO FILL IN ,JOB
Policy No Company EACH NO FEE ADDRESS
New Residential Bldgs &Pools
Certified copy is hereby furnished 1 &2 Family Sq Ft
$ — $ LOCALITY
Multi family Sq Ft NEAREST
Certified copy is filed with the county building inspection Residential Swimming Pools CROSS ST
department OWNER OR
FIRM NAME
Date Applicant Outlets Rec Light Sw Q MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY Tel No
COMPENSATION INSURANCE PLAN CHECK }
4.
APPLICANT
(This section need not be completed if the work involved Lighting Fixtures First 20 ADDRESS 0
by the permit is for one hundred dollars ($100) or less) Additional
Total No
I certify that in the performance of the work for which this CITY Tel No O
Fixed Appliances Not Over 1 HP
permit is issued I shall not employ any person in any manner PERMIT F_
so as to become subject to the Wrs Compensate n Laws Range_ Heater_D W APPLICANT W
o Oven _ Dryer_w M ADDRESS U)
Date ��A Applicant eQ1, Top — FAU —W H (/
pp , Z
Hood Fan _Other_ CITY ( Tel No C
NOTICE TO APPLICANT If after making this Certificate of Disp Room Air Cond_ S� 2 S d G, LICENSE O l/
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 PROCESSED B`—
with comply with such provisions or this permit shall be .Size&Type HP KW KVA or KVAR �—
deemed revoked
� Up to 1 Incl
FINAL
Over 1 to 10 Incl DATE�i�' 1 1
LICENSED CONTRACTORS DECLARATION VALIDATION
Over 10 to 50 Incl
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
ness and Professions Code and my license is in full force and
effect Services
License Num7,0, V Lic Class � 0 200 Amp Under 600 V �j `i Q 0
201 1000 Amp Under 600 V
Contractor '/4 Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole& Appurtenances
S
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit
License Law for the following reason (Section 7031 i5 Busi— Additional Sign Branch Circuits
ness and Professions Code) -q021 2 A
Misc Conduits&Conductors
I as owner of the property will do the work and the Other (See Complete Fee Schedule)— '
structure is not intended or offered for sale (Section # 00 e • 0 2
7044 Business and Professions Code) 2 0 0 1 0 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE a (Sub Total) to 0 0 1 3 U
issued(Sec 3097 Civ C)
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) 0 1 6'-8 1
Lender s Address PERMIT ISSUING FEE
s
I certify that I have read this application and state that the TOTAL FEE j
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring and
hereby author a presentatives of this County to enter upon
the ab n i roperty f inspection purposes
^� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee 7 Date