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HomeMy Public PortalAbout5136 AGNES AVE_Electrical__ WORKERS'COMPENSATION DECLARATION 76-810/81 APPUCATION FOR ELECTRICAL PERMIT {� I hereby'affirm that I have a certificate of consent to self insure, CE-806G �J or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy thereof(Sec.3800,Lab. C.) Policy No. I Company FOR APPLICANT TO FILL IN JOB Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE ADDRESS ❑ 1 & 2-Family,Sq.Ft. $ _ $ LOCALITY Certified copy is filed with the county building inspection department. LIC Multi-family Sq.Ft. NEAREST pt •1 CROSS ST. � 1' I / Co"lu Date Applicant Residential Swimming Pools OWNMER OR _ FIRNAME ' C CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL COMPENSATION INSURANCE ADDRESS 1 l� This section need not be completed if the work involved by the First 20 ( P CIT Y�� Tel.No. �-y permit is for one hundred dollars($100)or less.) Total No. Additional CHECKPLAff I certify that in the performance of the work for which this permit APPNICANT is issued, I shall not employ any person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS �2u ���P� Additional Total No. CITY Date Applicant Fixed Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this Certific to of Exemption,you should become subject 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 Z provisions or this permit shall be deemed revoked. Top FAU _ W.H. CITY 6 7 Tel.No. LICENSED CONTRACTORS DECLARATION Hood Fan. _ Other_ I hereby affirm that I am licensed under provisions of Chapter 9LICENSE OR (commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. — REG.NUMBER ,�j Class. Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. P C SSE,BY 5;���10-3 � Size&•Type HP,KW,KVA,or KVAR D o License Number L,�[fL Lic.Class Up to 1 Incl. FINAL V 1w T> l `O-'�p� (� / _� Over 1 to,1 O Incl. S ATE O Contractor /\j /�itf Date SCJ- / VALIDATION Over 10 to 50 Incl. U FINAL I am exempt under Sec. Over 50 to 100 Inc., BY W Over 100 n- B.&P.C.for this reason (n Services,Swbd.,MCC &Panelboards ® Z Date: 0- 200 Amp.Under 600 V Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole.& Appurtenances - ) HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit U_"C I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits for the following reason(Section 7031.5, Business and Professions s ` Code): TOTAL(AL _ h 21, m ❑ Misc.Conduits & Conductors CHECK, 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) ® k3± -.� and PIGE rofessions Code). t• i! ! °a 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) _ Civ.C.). , rLC` PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE � Lender's Address 5 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 to laws regulating Electrical wiring, and hereby authorize re entatives7 is unty to enter upon the above-mentioned roperty for ection oses. © SEE REVERSE FOR EXPLANATORY LANGUAGE � fO4 Si ure o Perm' ee / Date