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HomeMy Public PortalAbout5746 AGNES AVE_Electrical__ DEC 20-0019 s WORKERS' CI have cerci cafe of Z6A463 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT 11 heretfy.affjrm that 1 have a certificate of @iii enc to self. i EAS• i w1A e,'6r_a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS • fr,calertif_ieel copy thereof (Sec. 3800, Lab. C.) PoliCy,No. Company FOR APPLICANT TO FILL IN JOB '/' A n' 13Certifiedcopy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS WP /V e 5 Ave G`r ' LOCALITY Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft.'E�-�� � -- $ T%n^e / tion department. Multi-family Sq. Ft. NEAREST 'l l Residential Swimming Pools CROSS ST. W o gg M Date Applicant OWNER OR `!/�,�� FIRM NAME LVYr(G1J I2l�r►�a�L�Z CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 ADDRESS. (This section need not be completed if the work involved by Total No. Additional CITY–'�r tZ Cyl Tel. No. S the permit is for one hundred dollars ($100)or less.) PLAN CHECK Zq 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 We rs'Compen on Laws. Lighting Fixtures First 20 ADDRESS +( y Total No. Additional CITY Tel. No. UDate Applica t NOTICE TO APPLICANT: If, after m king this Cer ificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. — APPLICATION 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 Disp. — Room Air Cond. — LICENSE OR Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. CESS D BY- >- and Professions Code,and my license is in full force and effect. a. Size &Type HP, KW, KVA, or KVAR `5 Q License Number Lic. Class Up to 1 Incl. FINAL / U Over 1 to 10 Incl. DATE 2� ! VALIDATION cc Contractor Date 0 QOver 10 to 50 Incl. FINAL 1 am exempt under Sec. Over 50 to 100 Inc. BY W Over 100 p. B.&P.C. for this reason CL Date: Services, Swbd., MCC& Panelboards PW Z 0-200 Amp. Under 600 V — Signature 201 - 1000 Amp. Under 600 V Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V t SINGLE FAMILY Temp. Power Pole &Appurtenances i HOME OWNER-BUILDER DECLARATION s I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit ACCT. Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 3307 138.51[1 Professions Code): 1 ITEMS 14 I, as owner of the property, will do the work and the Misc. Conduits&Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , TOTAL 13483 . 50 Business and Professions Code). ;� (�;Code). -1 l CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CHANGEaTU the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE li l;i�-i� Chi 111/it/v9 Lender's Name PERMIT ISSUING FEE 6870 ] MMi� :31 Lender's Address n 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 eby authorize representatives of this County to enter upon th above-7n'io ed proer for inspecoory purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE I-7& StatuSature of er ittee Date ©s re