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Home My Public Portal About5925 AGNES AVE_Electrical__ _)RKERiO COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT • . „ ghat I have a certificate of consent to self insure, 76A663 s� ,.E,L.-cate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec.3800 Lab. C.) Q' Pd'�`-No. Company FOR APPLICANT TO FILL IN - 'JOB v F NO. EACH FEE ADDRESS �r �. Certified copy is hereby furnished: New Residential Bldgs.&Pools. LOCALITY 1 &2-Family,Sq. Ft. - $ $ I Certified copy is filed with the county building inspection NEAREST department. Multi-family Sq,Ft. CROSS ST. ��S "7 ti,i*✓✓9S Date Applicant Residential Swimming Pools ASSESSOR �J �� MAP BOOK �„�Q 7 PAGE �i+4�! PARCEL,-,5V 'j CERTIFICATE OF EXEMPTION FROM WORKERS` Outlets:Rea •Li ht Sw. k_— OWNER OR COMPENSATION INSURANCE g j+'O FIRM NAME n/r' _` ,�/,lJ -J! irst 20 MAL (This(This section need not be completed if the work involved by the -2 0fit} ADDRES � r permit is for one hundred dollars(5100)or less.) Total No. €=— Additional I certify that in the performance of the work for which this permit CITY , F Tel.N %-:P,� is issued, I shall not employ any person in any manner so as to PLAN CHECK become subject to the Workers' Compensation'Laws., Lighting Fixtures First.20 APPLICANT Total No. Additional ADDRESS Date Applicant RE LIOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,'you should become subject to the-Workers' Compensation OTHER APPLIANC S NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with SUCK PERMIT APPLICANT _ provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances [ �/C �✓ G✓.9� LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS f- Ae'�✓�' y.s I hereby affirm that I am-licensed under provisions of Chapter 9 Over 3 to 10 Incl. �-y (commencing with Section 7000) of Division 3 of the Business and — CITY Tel.r 2?,w LF �> T in 9~ Professions Code,and m license is in full force and effect. Over 10 to 50 Incl. y LICENSE OR i Class. Over 50 t0 100 Incl. .AEG.NUMBER Q. Over 100 DISTRICT N PROCESS yPl� O License Number Lic.Class JL(�L�`// Services,Swbd.,MCC&Panelbcards 0-399 Amp.Under 600 V FINAL O Contractor Date DATE ' El 400-1000 Amp.Under 600 V Z'� VALIDATION V I am exempt under Sec. W Over 1000 Amp.or Over 600 V FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES BY r fa Date: 15A,or 20A, 120V, Lighting or Recept. Z_ 1 To 10 Branch Circuits v Signature t 1 To 40 Branch Circuits 41 Or More Branch Circuits Exemption for Reg.Maint.Elect. 15A,20A,208V To 277V Lighting 6r.Circuits s SINGLE FAMILY Temp.Power Pole&Appurtenances f HOME OWNER-BUILDER DECLARATION''`t °g I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits =`=hY �04°i I; Code): -• i. IT_NJ 1, as owner of the property, will do the work and the structure. Misc.Conduits&Conductors is not intended or offered for sale (Section 7044, Business . Other(See Complete Fee Schedule) TO}AI- 1014, 70 and Professions Code). r_s '• !FJ4 ?;! 6:+ ° CONSTRUCTION LENDING AGENCY „ f-HANG E 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) Civ. C.) PLAN CHECKING FEE s3;[li}=91SI_3 1 r { Lender's Name 9 s--=^ 1 Ail 9.24 PERMIT ISSUING FEE Lender's Address I certify that I have read this application and under penalty of purjury state TOTAL FEE that the above information is correct. 1 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. SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATUREe5F.,PERM EOATE WORKER'S COMPENSATION DECLARATION 20-0019 DPW(t2-91) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self insure, 76A663 or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV. copy thereof(Sec. 3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE$ $Ft Sq. . LOCALITY — Certified copy is filed with the county building inspection 1&2-Family, _ NEAREST department. Multi-family Sq.Ft. CROSS ST. � Date Applicant Residential Swimming Pools ASSESSOR MAP BOOK ,�' PAGE C✓2-6 PARCEL 00 00 CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light Sw. FNAME OWN COMPENSATION INSURANCE L''h`4?%Nl' — /�• .4 iJr First 20 MAIL (This section need not be completed if the work involved by the Total No. Additional ADDRESS c1 permit is for one hundred dollars($100)or less.) I certify that in the performance of the work for which this permit CITY M ��- G T Tel.No. 4"07,7 /6 Z is issued, I shall not employ any person in'any manner so as to PLAN CHECK become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT Total No. Additional ADDRESS Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No. Exemption,you should become subject to the Workers'Compensation OTHER APPLIANCES NOT OVER 3 HP. provisions of the Labor Code, you must forthwith comply with such PERMIT p y Power Apparatus&Large Appliances APPLICANT , j-_^/ •- ,r/A G-1%IV provisions or this permit shall be deemed revoked. LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000) of Division 3 of the Business and CITY /,r C/7 el.N 2-j2-7-74 2 Professions Code, and my license is in full force and effect.. Over 10 to 50 Incl. LICENSE OR Class. >_Over 50 to 100 Incl. REG.NUMBER a License Number Lic.Class Over 100 DISTRICT NO. P ESSED BY 0 V Services.S bd., C &P ards fJ� �L �Jcc Contractor Date �1 0-39 Amp. d 600 V / 1 � DATE 0 ❑ I am exempt under Sec. 400-1000 Amp.Under 600 V tt7 �Q+ VALIDATION V Over 1000 Amp.or Over 600 VFINAL i'I a a B.&P:C.for this reason BRANCH CIRCUIT FEES BY -r_• € =r ;` •z-!Z Date: 15A,or 20A, 120V,Lighting or Recept. 1=�'f T� 1 To 10 Branch Circuits •s T�"iD Signature 11 To 40 Branch Circuits -f[•w _ F141 Or More Branch Circuits E_E( � A4.5 Exemption for Reg.Maint.Elect. 15A,207,208V To 277V Lighting Br.Circuits _ SINGLE FAMILY - - Temp.Power Pole&Appurtenances _`�[� a�'F_[ HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �.Yi31 j I hereby affirm that I am exempt from the Contractor's License Law for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits Code): ti::' D I, as owner of the property,will do the work and the structure Misc.Conduits&Conductors ?a_ €{€'1€:_+_, r 4 is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ~tc 's # { c and Professions Code). "" ' 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) &�7 Civ. C.) PLAN CHECKING FEE Lender's Name PERMIT ISSUING FEE p� Lender's Address TOTAL FEE 3. 1 certify that I have read this application and under penalty of purjury stateTfl that the 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. / SEE REVERSE FOR EXPLANATORY LANGUAGE SIGNATURE OF P MITTEE DATE