HomeMy Public PortalAbout5219 AGNES AVE_Electrical__ •q '
WORKERS'COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL'IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
Certified copy is filed with the count uild'n inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY
NEAREST � Q
tion d partment. Multi-family Sq. Ft. CROSS ST.
Date pplicant Residential Swimming Pools OWNER OR
FIRM NAME /V/U,C .*
CERTIFICATE OF EXEMPTIO RKERS' e- MAIL
Outlets: Re Light Sw.
COMPENSATION ISURACE
ADDRESS
This section need not be competed if the work involved b l . First 20
( Y Total No. Additional CITY 7—/C_ Tel. No.-Q96— , ¢3
the permit is for one hundred dollars ($100)or less.)
I certify that in the performance of Asn
ick this PL K
APPLICANT
permit is issued, I shall not employ anner2 Z11
so as to become/subject to the Workaws. Lighting Fixtures First 20 A - ADDRESS
/ �/�// Total No.� AdditionalSf'�' CEJCITY Tel:Date ApplicantFixed Appliances Not Over 1 HP PERMITNOTICE TO APPLICANT: If, after mcate ofAPPLICANTExemption, you should become sorkers' Range_ Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven — Dryer W.M. ADDRESS
with comply with such provisions or this permit shall be Top FAU W.H. — /�
deemed revoked. Hood Fan _ Other_ CITY �� Tel. Nogg/37.,5
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER 60 707 Class�/_-_7,/o
(commencing with Section 7000) of Division 3 of the Business Power Apparatus & Large Appliances DISTRICT NO, PROCESSED BY
and Professions Code,and my license is in full force and effect.
Size &Type HP, KW, KVA, or KVAR'
License Number 30-71_,57 Lic. Class Up to 1 Incl. FINAL
�D�lot�� � �glg� �— Over 1 ?o 101nc1. DATE r VALIDATION
Contractor Date Over 10 to 50 Incl.
I
FNAL
I am exempt under Sec. Over 50 to 100 Inc. F �,71/j LUB.&P.C. for this reason Over 100 r �
Date: Services, Swbd., MCC & Ponelboards / �
0 -200 Amp. Under 600 V j
Signature 201 - 1000 Amp. Under 600 V
C c
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole& Appurtenances 0 1 2 6 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License o c o o 0 7
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): ! 0 1 0 7 2 5•,
Misc. Conduits &Conductors 1 0 7 2 5
I, as owner of the property, will do the work and the v 0
structureis not intended or offered for sale (Section Other (See Complete Fee Schedule)_ J(�—gj/�
,
7044, Business and Professions Code). O
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 PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby author,' representatives of this County to enter upon
the above- nti ne property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign at mittee Date