HomeMy Public PortalAbout5120 AGNES AVE_Electrical_11/15/1995_air condition 4
WORKERS COMPENSATION DECLARATION iDist
CE 806 ,APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure CE Bose
or-a certificate of Workers Compensation Insurance or a certified r ' COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C) ! -
Policy No Company FOR APPLICANT TO FILL IN + ,r JOB '
❑ Certified copy is hereby furnished EACH` NO - ,FEE ADDRE CJ y S
New Residential Bldgs & Pools
❑ 1 & 2 Family Sq Ft $ — $ - LOCALI e,y L G
rCertified copy is filed with the county building inspection
department Multi family Sq Ft NEAREST L CROSS ST
Date Applicant Residential Swimming Pools OWNER OR j
I r 1 , v A + FIRM NAME10144 �f
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec— Light — Sw ? M MAIL l' r
COMPENSATION INSURANCE t ADD S CJS N e.5
(This section need not be completed if the work Involved by the ` First 20
Total No Additional " L e_,c . Tel
permit Is for one hundred dollars($100)or less) �, "
I certify that in the performance of the work+for which this permit 1 s PLAN C ECK _ -+00'
is issued I shall not+em to r an y > - APPLICANT
� p y any,person in an manner so as to � �
become subject to the Workers Compe ation Laws Lighting Fixtures First,20 ADDRESS `
) a tAj
Total No Additional I '
D�tt���b / S Applican 1 CITY Tel No
�� a F� ' g Fixed'Appliances Not Over 1 HP r vC f
OTICE TO APPLICANT If after, ma in this Certificate of
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW r
provisions of,the Labor Code you must forthwith comply with such Oven+_ Dryer _ W M ' e c—
provisions or this permit shall be deemed revoked ^ Top FAU _ W H o ~ W" ,
w��
LICENSED CONTRACTORS DECLARATION Hood Fan _ Other 0 I -eTel
I hereby affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond` - / a
(commencing with Section 7000) of Division 3 of the Business and 3 Cla� O
Professions Code and my license is in full force and effect +Power Apparatus& Large Appliances DISTRICT O t R� SED BY
L , Size&Type HP KW KVA or KVAR } µ F U
License Numbe�`J Lic Class t Up to 1-Incl FINAL
P�� 'e _/,�Le�rr/l G ^, j��b01S
1 to 10 Incl DATE �I 0
n r for 1yl� -1 /t�i6rd [J ! VALIDATION O
❑ Y 10 to 50 Incl w
FINAL U
I am exempt under Sec 50 to 100 Inc BY } W
a
B&PC for this reason 100 ' 41 Z
r C & Panelboa�ds 3Q J`�pDate Under 600 V 4S`gnature Under 600 V
❑ vermp or Over 600 V + ` C
Exemption for Reg Maint Elect I � a � *^ � 7 '/+
- SINGLE FAMILY »+ Temp Power Pole& Appurtenances i h KCTe®
HOME OWNER BUILDER'DECLARATION Sign with One Branch Circuit a r �n� 4 114u 60
I hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuits + +7.7t�a
for the following reason (Section 7031 5 Business and Professions ` g w1 ITEMS
' a
Code) I
i +
❑ MiseConduits & Conductors ti _ TOTAL — 114 m 6O
I as owner of the property will do the work and the structure 1 , ( 7 L
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)
�� 114s«t
and Professions Code) ° - ®° " "" y OV
CONSTRUCTION LENDING AGENCY ° `
GKWGE .00
I hereby affirm that there is a construction lending agency for the l '
performance of the work for which this permit is issued(Sec 3097 "PERMIT FEE `d (Sub Total)
Civ C) `' 0000-0001 11/15/99
, i
r PLAN CHECKING FEE �A y ! [ i �M 9e03`
Lenders Name r , 0 .7
PERMIT ISSUING FEE D r 0
Lenders Address 0 r4
I1certify that I have read this application and state that the above TOTAL FEE
information is correct I agree to comply with all County ordinances
IV-
and State laws regulating Electrical wiring and hereby authorize , s
' representatives of this County to enter upon the above mentioned
pro ty for inspection purposesT y -
SEE REVERSE FOR EXPLANATORY iLANGUAGE 7
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Signature of Permittee Date y
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