HomeMy Public PortalAbout5742 AGNES AVE_Electrical__ N 76A663
IY,, ' QRmE aCO COMPENSATION
aAce°rtlfipateLAoRATolOent to self CE806G '°'B' APPLICATION FOR ELECTRICAL PERMIT
insure, Gro certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. t Company FOR APPLICANT TO FILL IN JOB �[
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRES Ae
Certified copy is filed with the county building inspec- y, Sq. Ft. LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Dare Applicant OWNER /r_ ��,G A ,J���
FIRM NAME TOIGO �C
CERTIFICATE OF EXEMPTION FROM WORKERS' � 3 MAIL 7�2�G�cs Ake
-
(This
Rec Light Sw.
COMPENSATION INSURANCE ADDRESS
First 20 l� ? '
(This section need not be completed if the work involved by Total No.. Additional CITYrL,,A_e Tel. Noy�� �1
the permit is for one hundred dollars ($100)or less.)
PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
6/ Total No.� Additional
CITY Tel. No.
Date Ay Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO PPLICANT: If, after makin this Certificate of APPLICANT 041411C-A—
Exemption, you should become subject to the Workers' Range_ Heater—D.W.
Compensation provisions of the Labor Code, you must forth- Oven _ Dryer — W.M.— ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood Fan _ Other_ CITY Tel. No.
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG. NUMBER Class.
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PR E$ D BYCL
and Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances 6 . C).
Size & Type HP, KW, KVA, or KVAR' �` V
License Number Lic. Class Up to 1 Incl. FINAL \
Over 1 to 10 Incl. bd DATE VALIDATIOf� O
Contractor Date Over 10 to 50 Incl. L)
FI L
❑ LiJ
I am exempt under Sec. Over 50 to 100 Inc. O..'
B.&P.C. for this reason Over 100 fnz
Date: Services, Swbd., MCC& Panelboards /
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
DOver 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
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Prof ssions Code):
owner of the property, wil-I do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ '
7044, Business and Professions Code). 25 7 Z 8 A
u
CONSTRUCTION LENDING AGENCY # o o o o 0 2
1 hereby affirm that there is a construction lending agency for ( o o27.75
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). 0 0 o27,751,
Lender's Name PLAN CHECKING FEE ) 0.22-86
PERMIT ISSUING FEE D
Lender's Address O9�
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 authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes.16 SEE REVERSE FOR EXPLANATORY LANGUAGE
'Signature Sf Permittee Date