HomeMy Public PortalAbout6059 AGNES AVE_Electrical__ WORKERS COMPENSATIONDECLARATIf]N 76A66
YL
806GG (2 BO) APPLICATION FOR ELECTRICAL PERMIT
CE 8
I hereby affirm that I have a certificate of consent to self COUNTY`OF LOS ANGELES BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
Policy No Company
FOR APPLICANT TO FILL IN SOB / OS9 rM 46
piGt
New Residential Bldgs &Pools EACH NO FEE ADDRESS (7
Certified copy is hereby furnished 1 &2 Family Sq Ft $ — $ LOCALITY
Multi family Sq Ft — NEAREST
Certified copy is filed with the county building inspection CROSS ST C 4
department Residential Swimming Pools OWNER OR
FIRM NAME &NW IJ 4, J4 CXJ
Date Applicant Outlets Rec t5 Light �" Sw L MAIL
First 20
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE Total No Additional, CITY ADDRESS
, (►I! Tel No
r PLAN CHECK] }
z Lighting Fixtures First 20 APPLICANT yENL/1 -AACPJ to
(This section need not be completed if the work involved APPLICANT
�- � �� 4.0 P_4 U
by the permit is for one hundred dollars ($100) or less) ADDRESS 10 fd) o
Total No Additional Cr
I certify that in the'performance of the work for which this Fixed Appliances Not Over 1 HP CITY IS Tel No �Q����� 0
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 C.Its W
a.
Oven _ Dryer_W M ADDRESS601-ej
N
Date Applicant Top _ FAU _W H ! ND /¢ -1 Z
Hood _ Fan _Other_ CITY � Tel No tsb
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE OR
Exemption you should become subject to the Workers ' REG NUMBER Class
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCESSE Y
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP KW KVA or KVAR
Up to 1 Incl
FINAL
Over 1 to 10 Incl DATE VALIDATION
LICENSED CONTRACTORS DECLARATION +
Over 10 to 50 Incl
I herebyaffirm that I am licensed under p FINAL
provisions of Chapter Over 50 to 100 Inc
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
License Number Lic Class 0 200 Amp Under 600 V
ti 201 1000 Amp Under 600 V
Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances r
l
I hereby affirm that I~am exempt from the Contractors Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits +
ness and Professions Code) k
Misc Conduits&Conductors,
Ktilucture
as owner of the property will do the work and the Other (See Complete Fee Schedule)—
is not intended or offered,for sale (Section ti
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY,
> t
1 hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub Total)
issued (Sec 3097 Civ C) _ )I
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) 9200.2A
Lenders Address PERMIT ISSUING FEE # 0 00 0 0 2
I certify that I have read this application and state that the TOTAL FEE f ` 2 0 0 1 0 0
above information is correct I agree to comply with all County
ordman and State laws regulating Electrical wiring and 0 0 0 1 1 O 0 H
hereb a horize representativ this County to enter upon
the ov mentioned proper fo inspect on purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE O R 0 4f_8 0
Signature of Permit Date
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