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Home My Public Portal About5951 AGNES AVE_Electrical__ WORKERS COMPENSATION DECLARATION 63 CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT � CE 8 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANELE ND SAFETY Insure or a certificate,of Workers Compensation Insurance or a certified cdpy thereof(Sec 3800 Lab C) �g� FOR APPLICANT TO FILL IN SOB Policy No Company ADDRE New Residential Bldgs &Pools EACH NO FEE Certified copy is hereby furnished 1 & 2 Family Scl Ft $ — $ LOCALITY Certified co y g inspection family Scl Ft NEAREST copy is filed with the count buildin ins ection Residential Swimming CROSS ST Pools P42 A department OWNER OR FIRM NAME �) Q Date Applicant Outlets Rec—Light_ Sw MAIL First 20 ADDRESS CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY Tel No } COMPENSATION INSURANCE a PLAN CHECK O APPLICANT f (This section need not be completed if the work involvedLighting Fixtures U — First 20 ADDRESS by the permit is for one hundred dollars ($100) or less) Total No Additional 0 I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No �- permit is issued I shall not employ any person in any manner PERMIT U so as to become subject to the Workers Compensation Laws Range_ Heater_D W APPLICANT 0W. Oven _ Dryer_W M ADDRESS N (`�► Date Applicant /� Top _ FAU —W H 6 � fx-�.a�� Hood _ Fan —Other CITY Roaj q Tel No JC_ CZ NOTI E TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE OR Exemption you should become subject to the Workers REG NUMBER 3 10 7 Class Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NOES D BY with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVAROle deemed revoked Up to 1 Incl FINAL PRO C/ LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl Over 1 to 10 Incl DATE 1(� VALIDATIO I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINA 9 (commencing with Section 7000) of Division 3 of the Busi Over 100 BY ness and Professions Code and my license is in full force and effect Services � �f�'/l�J� n 0 200 A Under 6600 License Number p�/ Lw Class�'"� �� 201 1000 Amp Under 600 V Contractor 2C Date Over 1000 Amp or Over 600 V r HOME OWNER BUILDER DECLARATION 1 Temp Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit Additional Sign Branch Circuits License Law for the following reason (Section 7031 5 Busi ness and Professions Code) Misc Conduits& Conductors 0 I as owner of the property will do the work and the Other (See Complete Fee Schedule)— 1 2 7 3 a y structure is not intended or offered for sale (Section 7044 Business and Professions Code) l # ° ° ° ° ° 2 CONSTRUCTION LENDING AGENCY 1 I hereby affirm that there is a construction lending agency 2 ° ° 1 g 5 0 for the performance of the work for which this permit is PERMIT FEE (Sub Total) issued (Sec 3097 Civ C) ° ° e 1 9 5 0 Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) Lender s Address PERMIT ISSUING FEE 0715-80 , I certify that I have read this application and state that the TOTAL FEE 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 abo mentio ed property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE i Al Signature of Permittee to ' v RKERS' SOMPENSATION DECLARATION -663 10/81 CE-806G APPLICATION FOR ELECTRICAL PERMIT YY C J�Itereby a firm that 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. J• Company FOR APPLICANT TO FILL IN JOB ❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS L� eS New Residential Bldgs.& Pools ❑ 1 & 2-Family,Sq.Ft. $ — $ LOCALITY Certified copy is filed with the county building inspection department. Multi-family Sq.Ft. — NEAREST CROSS ST. Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' & �r !r� COMPENSATION INSURANCE Outlets:Rec Light LZ Sw. — `�� ADDRESS lj (/ (This section need not be completed if the work involved by the First 20 permit is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.No. S�?� I certify that in the performance of the work for which this permit PLAN CHECK to an APPLICANT is issued, I shall not employ y y person in any manner so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 75 ADDRESS Additional 5Z Total No.� CITY Tel.No. Date Applicant Fixed Appliances Not Over 1 HP NOTICE TO. APPLICANT: If, after making this. Certificate of PERMIT Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT provisions of the Labor Code, you must forthwith comply with such Oven Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked. Top FAU W.H. _ LICENSED CONTRACTORS DECLARATION Hood Fan —L Other_ CITY Tel.No. I hereby affirm that I am licensed under provisions,of. Chapter 9 Disp. Room Air Cond. � LICENSE OR (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Class. Professions Code,and my license is in full force and effect. DISTRICT NO. PROC BY Power Apparatus& Large Appliances ,..� O � a' Size& Type HP,KW,KVA,or KVAR 't) f O d License Number Lic.Class Up to 1 Incl. FINAL V Over.1 to 10 Incl. DATE Contractor Date v VALIDATION ❑ Over 10 to 50 Incl. 0 FINAL Q I am exempt under Sec. Over 50 to 100 Inc. !/ W ° B.&P.C.for this reason Over 100 C- (n Date: Services,Swbd.,MCC&Panelboards ® Z 0-200 Amp.Under 600 V f5� 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 HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ' Z. 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); fp( •"W> /y[iJ I,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) -';, and Professions Code). '� }' `�� 4 _ 20 CONSTRUCTION LENDING AGENCY ., rTL A__ 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 Lender's Name PERMIT ISSUING FEE D -c { Lender's Address I certify that I have read this application and state that the above TOTAL FEE 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 prop ty for inspectio purposes. - SEE.REVERSE FOR EXPLANATORY LANGUAGE nature of rmittee Date