HomeMy Public PortalAbout5117 AGNES AVE_Electrical__ —�. *ntl ;✓YORKERS COMPENSATION DECLARATION CE76A663 806G 10/81 APPLICATION FOR ELECTRICAL PERMIT
CE 806
I hereby affirm that I have a certificate of consent to self insure r
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES - BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C)
S
Policy NO t k Company FOR APPLICANT TO FILL IN Grp JOB
❑ Certified co ADDRESS
copy is hereby furnished New Residential Bldgs & Pools + EACH NO FEE y
❑ $ LOCALITY
Certified copy is filed with the county building inspection ;1 & 2 Family Sq Ft — $ �^
department ' y Multi family Sq Ft ' — NEAREST t r
CROSS ST ,
Date Applicant a Residential Swimming Pools i' OWNER OR �/ b ,
PP t a i v , FIRM NAME ` �✓V
CERTIFICATE OF EXEMPTION FROM WORKERS S R�< IL 1
COMPENSATION INSURANCE Outlets Rec Light �"� , 4 i1 ADDRESS L k
J s First 20 _`fit *d V
This section need not be completed If the work Involved by the y p
Total No D Additional r CIT+Y,'y / Tel N 6� [+
permit Is for one hundred dollars1 $�00)or less) eo
I
certify that in the performance of the work for which this permit PLAN CHECK - / 9
a Y p p f+ a Y t, APPLICANT ,
s issued' I shall not employ,any person in any manner so as to ti , v ,
become subject to the Workers Compensation Laws Lighting Fixtures First20ADDRESS
v Additional + _
� ` G Total Nor f CITY f �` e p tt�4 Tel N
Date Applicant t, ' r� J � " ° � � `� �
Fixed Appliances Not Over 1 HP o 1 PERMIT
r NOTICE TO APPLICANT If after making this Certificate of f APPLICANT
Exemption you should become subject to the Workers Compensation Range_ Heater= DW _ v y 1k _ _ d
provisions of the Labor Code youtmust forthwith comply with such Oven _ Dryer _ W M ADDRESS
provisions or this permit shall be deemed revoked r a Top — FAU WH--
LICENSED'
H^_LICENSED CONTRACTORS DECLARATIONs , CITY r Tel No l
roHood Fan Other_
t I hereby affirm that I am licensed under provisions oft Chapter 9 " H LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and Disp — Room Air Cond —+ i REG NUMBER Class
Professions Code BY 1 andim license iin full force and effect . D
y s, Power Apparatus& Large Appliances �i DISTRICT NO PROCE ,
Size& Type HP KW KVA or KVAR �((/ G
License Number 5/A3-!�? Lic Class Ig Up to 1`Incl ° t FINAL U
,��—�_g
J Over 1.to 10 Incl } DATE
Contractor l'LrrLy.]� ��� ate A DATION 0
Over 10 to 50 Incl '� I--
❑ I am exempt under Sec ` o Over 50 to 100 Inc + FIN e 1 W
B&PC for this reason Over 100 - i N
Services Swbd MCC& Panelboards ' ' f s Z
Date 0 200 Amp Under 600 V k r
Signature _ 201 1000 Amp Under 600 V L :❑ 910 ,0 A Over 1000 Amp or Over 600 V " 3
Exe��qaint ElectIr# o00,002 K
SINGLE FAMILY Temp Power Pole& Appurtenances
HOME OWNER BUILDER DECLARATI r Sign with One Branch Circuit " o o (� (L Q Q
I hereby affirm that I am exempt from the Contract r s License Lawfor u _ d A
Sign r
Code) Additional Si Branch Circuits following reason (Section 7031 5 Business and Professions g r e 3 0 0 0 =
44.00
(� + Wisc Conduits & Conductors y4 () 2 2 3`' 8
lo�l I as owner of the property will do the work and the structure � s r
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) ,
and Professions Code) o !
e CONSTRUCTION LENDING AG ENC
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) 3 r r 1
CIV Ci) I
PLAN CHECKING FEE
Lenders Name ° k i ' r
1 PERMIT ISSUING FEE
Lenders Address' /1 t
I certify that I have read this application and state that the above + TOTAL FEE
information is correct I agree to comply with all County ordinances
and State laws regulating Electrical wiring and hereby authorize
represeUjaLueQ of this Coun to upon the above mentioned
prop y for in ec p s
ti '�� �C/ •-• SEE REVERSE FOR EXPLANATORY LANGUAGE
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Si at of Per tee
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