HomeMy Public PortalAbout5211 AGNES AVE_Electrical__ IVWORKERS COMPENSATION DECLARATION 63 10/81 APPLICATION FOR ELECTRICAL PERMIT
h. yaffirm that J have o certificate of consent to self CE CE 8 8066
insure or a certi icate of Workers Compensation Insurance COUNTY OF LOS ANGELES / e BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) - /
Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE
❑ 1 & 2 Family S Ft $ — $ LOCALITY
Certified copy is filed with the county building inspec Y q
tion department Multi family Sq Ft ' CROSS NEARESTT �7�T �S
Date Applicant Residential Swimming Pools OWNER OR ` /
�� �Q FIRM NAME OR _ }��/G24P-1 U
CERTIFICATE OF EXEMPTION FROM WORKERS Re,52 MAIL
Outlets Re
COMPENSATION INSURANCE �� ADDRESS
This section need not be completed if the work involved b First 20
( p y Total No CITY Tel No
the permit is for one hundred dollars (;100)or less ) Additional Q
that in the performance of the work for which this PLAN CHECK
I certify P � � APPLICANT
permit is issued I shall not employ any4personiy mannerso as to become sublect to the Workerson Laws Lighting Fixtures First 20 a ADDRESS
BTotal No�3 Additional 3 CITY TeDate s Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after maficate of �^Exemption you should become s Workers Range_ Heater-D W ; APPLICANT �Gd.�1o.�/ �L EGA J E�
Compensation provisions of the Lo or Code you must forth Oven _ Dryer _ W M ADDRESS /S < _ E W,/&
with comply with such provisions or this permit shall be Top FAU L W H —
deemed revoked Hood j Fan _Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION LOR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp J� Room Air Cond RICENSEEG NUMBER 7 l� Class -/0
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCESS BY r
and Professions Code and my license is in full force and effect Power Apparatus& Large Appliances
�D��37 G' /O Size &Type HP KW KVA or KVAR , U r U
License Number Lic Class _ �` Up to 1 Incl 6U FINAL
ad
Contractor L'D�A'y �` Date 7 / Over 1 to 10 Incl DATE �� Z�� VALIDATION O
ElOver 10 to 50 Incl FIN ~
I am exempt and Sec Over 50 to 100 Inc BY
B&P C for this reason Over 100
Date
Services Swbd MCC& Ponelboards / //
0 200 Amp Under 600 V CJ
Signature 201 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Moint Elect
SINGLE FAMILY Temp Power Pole &Appurtenances Q
HOME OWNER BUILDER DECLARATION a 7J 2 7 A
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s License o 0
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits i 0 0 0 2
-.r
Professions Code) 2 0 1 1 8 0 0
❑ 1 as owner of the property will do the work and the Misc Conduits 8 Conductors
structure is not intended or offered for sale (Section
Other (See Complete Fee Schedule)_ ► 0 0 1 1 u 0 0 0
7044 Business and Professions Code)
07,01 -83
CONSTRUCTION LENDING AGENCY r
�I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name D
PERMIT ISSUING FEE J
Lender s Address
I certify that I have read this application and state that the TOTAL FEE �r
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring and
hereby authors representatives of this County to enter upon
the above t d property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
ign Permittee Date