HomeMy Public PortalAbout6006 AGNES AVE_Electrical__ t WORKERS' COMPENSATION DECLARATION CE-806G-663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby,affirm that hat I CE
have a certificate of consent to self insure, " .
or a certific-Ate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy t�y-pof(Sec. 3800,Lab. C.)
Policy No. - Company FOR APPLICANT TO.FILL IN JOB
❑ Certified copy is Hereby furnished. EACH NO. FEE- ADDRESS (O
New Residential Bldgs. & Pools
❑ 1 & 2-Family, S Ft. $ — $ LOCALITY
•Certified copy is filed with the county building inspection y q
department. Multi-family Sq.Ft. — NEAREST
CROSS ST.
Date Applicant Residential Syiimming Pools OWNER OR,.
'I FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
Outlets:Rec Light Sw.
' COMPENSATION INSURANCE t Q`• � � ADDRESS '
(This section need'not be completed if the work' • ,� First 20-
p involved by the Total No.�-// Additional CITY Tel.No.
permit is for one hundred dollars ($100) or less.) -
PLAN CHECK
I certify'that in the performance of the work for which this permit APPLICANT
is issued, I shall not employ any- erson.in anyii manner so as to
become subject to the.,Workers'C pen.,ation L w Lighting Fixtures First 20 ' ADDRESS
Qfi Additional
Date�'-7--G "<6 Applteemed
Total No. -,� CITY Tel.Na
NOTICE TO' APPLICANT:. Ifking this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption,you should becomehe Workers'Compensation Range_ Heater_ D.W. APPLICANTprovisions of the Labor Code, rthwith comply with such Oven _ Dryer _ W.M. — ADDRESS S pr4�L rf�3'OW
provisions or this permit shall revoked; Top — FAU - — W.H. —
LICENSED CONTRACTORS0ECLARATION CITY �y Tel.No.
' Hood — Fan Other_
I hereby-affirm that I am-licensed under proKisions of Chapter 9 Disp. — Room`Air Cond. LICENSE OR C Class.
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force an .d effect. DISTRICT NO2ESSED BY
. � Power Apparatus&-Large Appliances
/ Size& Type HP, K /��`/p,,or KVAR e� O
License Number S27 STY Lia ClaS\ T Up J/ �l FINAL U
d�a r Q
Over 1 to 10 Incl.. DATE
/;('l �ZZ VALIDATION
ContractoN/ "'r+`+�'�d� rL Date b Over 10 to 50 Incl. 0
❑ FINAL (�
I am exempt under Sec. I Over 50 to 100 Inc. BY
B.&P.C.for this reason Over 100 a
N
Serv' S Panelboards _Z
Date:_ � m .Under 600 V � /
Signature 1000 Amp. Under 600 V
❑ ! Over 1000 Amp. or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole& Appurtenances ACCT.HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ACCT.V
I hereby affirm that I am exempt from the Contractor's License Law n
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3303r 195®LIQ
Cade): 1 ITEMS 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) _
TOTAL
1-9 as(30
and Professions Code). / CHECK
HEC 4C• 195.00
95o00
CONSTRUCTION LENDING AGENCY GRANGE °00
I hereby affirm that there is a construction lending agency for the 4
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) �'7'
Civ. C.).
PLAN CHECKING FEE 1.lu00-0001 .1/26/96
.Lender's Name
PERMIT ISSUING-FEE 4474 1 AM10d21
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
re resentatives of this County to enter upon the above-mentioned
pr rty foro
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�• ^ SEE REVERSE FOR EXPLANATORY LANGUAGE
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*Signat Permitte Date
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