HomeMy Public PortalAbout5822 AGNES AVE_Electrical__ WORKERS COMPENSATION cafeDECLARATJON
corse 76A663 10/81 APPLICATION FO ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE 8066
insure or a certificate of Workers Cornpensation Insurance COUNTY OF LOS ANGELES � BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) /
Policy No—Company FOR FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
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Certified copy is filed with the county building inspec 1 & 2 Family S 9 Ft $ $ LOCALITY
tion department Multi family Sol Ft — NEAREST
CROSS ST
Date/�
l2_J__9'&_Applicant Residential Swimming Pools OWNER O
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKER§J Outlets Rec�Light�Sw MAIL
COMPENSATION INSURANCE 9(� 7 ADDRESS
First 20
(This section need not be completed If the work involved by Total No Additional CITY v Tel No
the permit is for one hundred dollars ($100)or less ) PLAN CHECK
1 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
� Additional CITY �^
Date � Applicant I Total No �� � c el No
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICANT a C �
Al
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..7,7,/
with comply with such provisions or this permit shall be Top _ FAU —W H —
deemed revokedCITY S,,,, Tel No g Lf f
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other
Disp _ Room Air Cond LICENSE OR L Class
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO O
�l5 PROCESSED BY
and Professions Code and my license is in full force and effect F/+}
_ � ) Size &Type HP KW KVA or KVAR / O
License NumberS+4 Lic Classes Up to I Incl FINAL V
Contractor -itgate 1a J��S Over 1 to 10 Incl DATE Z� �(� VALIDATION 0
❑ Over 10 to 50 Incl V
FINAL
I am exempt under Sec Over 50 to 100 Inc BY �.. LU
B 8P C for this reason Over 100 v7
Date
Services Swbd MCC & Ponelboards , Z
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect
SINGLE FAMILY Temp Power Pole &Appurtenances ;27266A
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit # 0 0 0 0 0 2
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
Professions Code) 2 ° 2 3 0 0
Elas owner of the property will do the work and the Misc Conduits 8 Conductors a o 0 2 3 0 0 u
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 007044 Business and Professions Code) 1 2'0 1 -8 3
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 PERMIT FEE (Sub Total) VG
(Sec 3097 Civ C ) /
PLAN CHECKING FEE
Lender s Name f (9 �
Lender s Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE /QC
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
ov m ntioned er�for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE J
gnature o Permittee Date