HomeMy Public PortalAbout5943 AGNES AVE_Electrical__ S COMPENSATION DECLARATION 63 10/81 APPLICATION FOR ELECTRICAL PERMIT
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m 0 0 CE 8I have a certificate of consent to self CE 806G
insure or a c�rtificote of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY lul
8r a certified copy theFeof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS
Certified copy is filed with the county building mspec 1 & 2 Family Sq Ft $ _ $ LOCALITY /
on de artment Multi family Sq Ft c NEAREST
�b�� Residential Swimming Pools CROSS ST
Date Applicant ti WNER OR
FORM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec��Light I/ Sw nh MAIL COMPENSATION
f /y�
COMPENSATION INSURANCE oCV Q ADDRESS rJz kk5
(This section need not be completed if'the work involved by S-qFirst 20
the permit is For one hundred dollars ($100)or less ) Total No Additional CITY Tel No 7 J
PLAN CHECK s
I certify that .n the performance of the work for which this APPLICANT
permit is issued 1 shall not employ any person in any manner
so as to become subject tc the Workers Compensation Laws Lighting Fixtures u First 20 1571
ADDRESS
" �� Total No i� Additional
~ r CITY Tel No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of t
Exemption you should become subject to the Workers iRange_ Heater_D W L APPLICANT
Compensation provisions of the Labor Code you must forth Oven Dryer — W M — ADDRESS ;
with comply with such provisions or this permit shall be ITop ' FAU W H —
deemed revoked Hood _ Fan CITY �. Tel No 7 �
LICENSED CONTRACTORS DECLARATION �Other_
p p Disp Room Air Cond LICENSE OR Class J }
I herebyaffirm 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 b DISTRICT NO PROC BY CL
andProfessions Code and my license is in full force and effect s� /� U
Size &Type HP KW KVA or KVAR �•/ (1
License Nu�e, -7Lic Ciass /0 OUp to 1 Incl FINALC7(d Over 1 to 10 Incl DATEContractDate V DATION W
F-1
Over 10 to 50 Incl FIN nee
I am exempt under Sec Over 50 to 100 Inc B [L
j
B &P C for this reason Over 100 Z_
Date Services Swbd MCC& Panelboards '1
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 >
SINGLE FAMILY Temp Power Pole & Appurtenances
HOME OWNER BUILDER DECLARATION 2 4 2 6.4 A
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits # 0 0 0 0 0 2
Law for the following reason (Section 7031 5 Business and
Professions Code) 4
❑ I as owner of the property will do the work and the Misc Conduits&Conductors A ° a 8 l 50
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ 10 a o 8 1 505
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 0320-86
j hereby affirm that there is a construction lending agency for
the performance of the work for which this permit .s issued PERMIT FEE (Sub Total)
(Sec 3097 Civ C ) 4
PLAN CHECKING FEE '
Lender s Name
i PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and`state that the TOTAL FEE _ h
above information is correct I agree to comply with all County
ces and State laws regulating Electrical wrong and
hereby.au orize representat. County to enter upon
entione I a es
s
t .-F�S/EE�REVERSE FOR EXPLANATORY LANGUAGE
ignature of Perm" Date �r—