HomeMy Public PortalAbout5803 AGNES AVE_Electrical__ ,r
WORKERS COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate
806ate of consent to self insure CE sosG
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
cop6.thereof Sec 38 ab C) ( �J�` ' C
" Policy No t Compan;�5 6k i c` 13s FOR APPLICANT TO FILL IN ' ADDRESS
❑
Certified copy is hereby furnisCJ
hed New Residential Bldgs & Pools EACH NO FEE
❑ $ _ $ LOCALITY
Certified 1 & 2 Family Sq Ft J -
copy is filed with the county building inspection NEAREST
dept ne2a Multi family Sq Ft '
E CROSS ST
Date Applicant Residential Swimming Pools OWNER OR
pp kqbj FIRM NAME
CERTIFICATI-OF EXEMPTION FROM WORKERS - 4 0 MAIL /1 r
,COMPENSATION INSURANCE Outlets Rec Light Sw + ADDRESS V us
First 2
(This section need not be completed If the work Involved by the Total No Addit o0nal * A ' CITY I No �a
,permit IS for one hundred dollars($100),or less) i ; C' PLAN CHECK
I certify that in the performance of the work for which this,permit APPLICANT
is issued sI shall not employ any person In any manner so as to
become subject to the Workers Compen tion Laws_ , Lighting Fixtures First 20 ADDRESS a
a, Additional _
1 Total No CITY Tel No
Date v Applicant'
— Fixed Appliances Not Over 1 HP PERMITap
NOTICE TO APPLICANT, If after making this Certificate of APPLICANT o yllp
.I`' 4
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW _W IVI ,
provisions of the Labor Code you must forthwith comply with such Oven Dryer W M _ ADDRESS
12 )
provisions or this permit shall be deemed revoked Top FAU, WH
CITYel No -O
LICENSED CONTRACTORS DECLARATION Hood Fan Other_ a_n
OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond EGNSE NUMBER17
Class C
(commencing,with Section 7000) of Division 3 of the Business and
Professions Code and my license is in full force and effect Power-Apparatus& Large Appliances DISTRICT O / , PROCES D e1
(� I ��t ► Size& Type HP KW KVA or KVAR �Q/ Q
License Numb r a` / Lo Class �'� _�� Up to' 1 Incl ° FINAL V�
Over 1 to 10 Incl e DATE �� VALIDATION O
Contractor �at�e ' �' a ' F—
'� Over 10 to 50 Incl FINAL " C.>
❑ I am exempt under Sec Over 50 to 100°Inc BY , �. d
B&P C for this reason Over 100 N
Services Swbd MCC& Panelboards 1 ' , Z
Date 0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V `
I ❑ _ i Over 1`000 Amp or Over 600 V a
Exemption for Reg Maint Elect
SINGLE FAMILY Temp Power Pole& Appurtenances 2
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractors License Law `C I 8,
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits 04
Code) 3307 _ 33.50
❑ Misc Conduits & Conductors
I as owner of the property will do the work and the structure T
is not intended or offered for sale (Section 7044 Business Other (See Complete Fee Schedule) _ TOTAL ITEPiS 4
and Professions Code) , I V I RL 33.50
CONSTRUCTION LENDING AGENCY MICK 33o5O
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 r (Sub Total) — wlir'H'IE
0
Civ C)
,
PLAN CHECKING FEE
Lenders Name 7710/89
PERMIT ISSUING FEE � 43971 M11:26Lenders Address J'
I certify that 1 have read this application and state that the above TOTAL FEE _ r"
1 information is correct 1 agree to comply with all County ordinances
and State laws regulating Electrical wiring and hereby authorize n 1 t
representatives of this County to enter upon the above mentioned
property for inspection purpos s
SEE REVERSE FOR EXPLANATORY LANGUAGE
U /
Signature of Permitted Date