HomeMy Public PortalAbout5813 AGNES AVE_Electrical__ f 1 r
�ORKERS COMPENSATION DECLARATION 76A663 10/81
T APPLICATION FOR ELECTRICAL PERMIT
CE 806G
� Q%�m�';o ffrpro th t I have a certificate of consent to self insure
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereoF(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished New Residential01dgs & Pols EACH NO _ FEE, ADDRESS
❑ Certified copy is filed with the county budding inspection 1 & 2 Family Sq Ft $ — $ LOCALITY
department^ Multi family Sq Ft •— NEAREST ` � J
Residential SwimmingPools CROSs ST J
_ Date Y Applicant 1 , K OWNER OR ;
' r I s�l FIRM NAME
i CERTIFICATE OF EXEMPTION FROM WORKERS r Outlets Recc JfJ LlghtC 0 Sw M
x } t i<'\ �t MAIL
COMPENSATION INSURANCE ! ti- t ADDRESS S _ /\j f�L)
(This section need not be completed if the work involved by the Qom) First 20 CITY Tel No p if
permit is for one hundred dollars ($100) or less) Total No f>v Additional Zrj
I certify that in the performance of the work for w is this permit ' PLAN CHECK 1
is issued I shall not employ an Se APPLICANT f
y y per on 5m any ann�r so as to
become subject to the Workers Com ation La s ^t Lighting Fixtures First 20 • ADDRESS
Total No Additional r
Applicant CITY Tel No 7
`Date ��yp"�,�mac ��
NOTICE O A PLICANT If afte ma ing this Certificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT �JJ�Wvl"� p;v�po�L
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW
provisions of the Labor Code you must forthwith comply with such Oven _ Dryer W M { ADDRESS r
provisions or this permit shall be deemed revoked Top — FAU WH CITY Tel No
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_
" I hereby affirm that I am licensed under,provisions of Chapter 9 LICENSE OR ,
`(commencing with Section 7000) of Division 3 of the Business and Disp — Room Air Cond REG NUMBER 't Class
Professions Code and my license is in full force and effect DISTRICT NO PROCESS Y
Power Apparatus& Large Appliances
M
Size& Type HP KW KVA or KVAR` ` O
License Number Lic Class ti Up to 1 Incl' FINAL
Over 1 to 10 Incl DATE u �r1U V 19 2
Contractor Date `/ i° LL O
❑ Over 10 to 50 Incl
A r� ° °
BYv
I am exempt under Sec Over 50 to 100 Inc 7250
W
B&P C for this reason = Over 100 y I i� i1 7 2 5 9 5 CLN
Services Swbd-MCC& Panelboards , Z
Date 0 200 Amp Under 600 V a
Signature ° 201 1000 Amp Under 600 V Y
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Marnt Elect ' ' ,
s"
1 SINGLE FAMILY 4 Temp Power Pole& Appurtenances s v
HOME OWNER BUILDERI,DECLARATION ' Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractors License Law
for the following reason(Section 7031 5 Business and Professions Additional Sign Branch Circuits t
Code) It
'S p
Misc Conduits& Conductors
• I as owner of the property will do the work and the structure I y
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) r
and Professions Code) x n
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(Sec 3097 PERMIT FEE (Sub Total) a
Civ C) -
PLAN CHECKING FEE
w Lenders Name
PERMIT ISSUING FEE r
Lenders Address
I certify that I have re thisr application and state that the above • TOTAL FEE
nforIsen
n is correct agree to comply with all County ordinances
and i laws regu t g Electrical wiring and hereby authorize t r
reprees oft sountyoenter upon the'above mentioned
propi purpose
j SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee 0aTit