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HomeMy Public PortalAbout5703 AGNES AVE_Electrical_2/7/1994_upgrade service amp WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT I heGe6y.affirm that I have a certificate of consent to self insure, 76A663 or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORkS BUILDING AND SAFETY DIV. copy thereof(Sec. 3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN tlDBDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE OCALITY ❑ $ $Ft Sq. . — Certified copy is filed with the county building inspection 1 &2-Family, _ NEAREST department. Multi-family Sq.Ft. CROSS ST. Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK AQE CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec._Light Sw. ORM NAMR COMPENSATION INSURANCE j First 20 MAIL Total (This section need not be completed if the work involved by the ADDRESS ? F permit is for one hundred dollars($100)or less.) Total No. Additional o I certify that in the performance of the work for which this permit CIT Tel.No. is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional '®� �y �if ADDRESS �Date� Applica RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLIGANT: If, after making this Ce CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such PERMIT p y Power Apparatus&Large Appliances PLICANT provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION Size'&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Over 3 to 10 Incl.Over 10 to 50 Incl. ClT / 1.*VTel. �� O Professions Code,and my license is in full force and effect. LICENSE OR } Over 50 to 100 Incl. REG.NUMBER Class O O /�i�49_ O. a i• —/is Over 100 DISTRICT NO. P C ED BY 0 License Number Sbs!G%V� Lia Class Services,-Sv�lcy,MCC ciellbAar c J� ,p� liL cr s/J�tF��✓ irF��U( 60��� FINAL 0 V/Contr�� �� C©- DatP ! 399 A nd 0 DATE f 0 ❑ �400-1000 Amp.Under 600 V � � "�(, y1 VALIDATION U I am exempt under Sec. W Over 1000 Amp.or Over 600 V FINAL d B.&P.C.for this reason BRANCH CIRCUIT FEES BY Z Date: 15A,or 20A, 120V,Lighting or Recept. — 1 To 10 Branch Circuits Signature 11 To 40 Branch Circuits ❑ 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION _• :s I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): T717- 1, 7_I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors .rr� is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _r a r i 4!:p ® 'ii -_¢ and Professions Code). r ".HECK. Fi CONSTRUCTION LENDING AGENCY C11"h4` E f 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.) f'3`I js—a 2 PLAN CHECKING FEE Lender's Name ^ 3- 'f PERMIT ISSUING FEE �! JV _1 tISr1==i'. Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE 3, that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby authorize representatives of this County to enter upon the above.-mentioned property for inspection purposes. y q SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF PERMITTEE DATE