HomeMy Public PortalAbout6327 AGNES AVE_Electrical__ r
WORKERS COMPENSATION DECLARATION CE 863 _10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE 8066
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a,certified copy thereof (Sec 3800 Lab C )
Policy No—Company' FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
❑ 1 & 2 Family S Ft $ = $ LOCALITY
Certified copy is filed with the county building mspec Y q
tion department Multi family Sq Ft NEAREST n
CROSS T
Date Applicant OWNER
Residential Swimming Pools OWNER
ORM
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec�Light�Sv, MAIL
COMPENSATION INSURANCE ADDRESS
This section need not be completed if the work involved b First 20
( p Y Total No�` v Additional CITY Tel Not(y?
the permit is for one hundred dollars ($100)or less )
I certify that in the performance of the work for which this APPLICANTPLAN C C
permit is issued I shall not employ any person in any manner
so as to become subject to the Wor C pe ati n L s Lighting Fixtures First 20 ADDRESS
Total No Additional y
Date�� ��' Apphcant CITYb. Tel No
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this ertificate of APPLICANT
Exemption you should become subject to the Workers Range_ Heater_D W —
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M — ADDRESS j
with comply with such provisions or this permit shall be Top — FAU —W H —
deemed revoked Hood Fan _Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION I LICENSE OR
1 hereby affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond REG NUMBER O e Class e+
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROC ED BY
and Professions Cre and my license is in full force and effect Power Apparatus 8 Large Appliances �
/ { Size &Type HP KW KVA or KVAR 0
License Number O I is Class (2 —10 Up to 1 Incl FINAL U
DATEmn
r/�f Over 1 tot 10 Incl ` �l VALIDATION 0
Contractor FINAL {L
ate ,�
Over 10 To 50 Incl 0
ElI am exempt under Sec Over 50 To 100 Inc BY m+� � CL
B 8P C for this reason
Over 100 Z
Date Services Swbd MCC& Ponelboards 00. �4F
0 200 Amp Under 600 V �dA 41,3
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 ;-969 1 9
HOME OWNER BUILDER DECLARATION Sign witH-One Branch Circuit # o o a o a 2
1 hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and l 2 a - 4275
Professions Code)
❑ I as owner of the property will do the work and they Misc Conduits&Conductors - 4275,1
Complete Fee Schedule Com fSee
structure is not intended or offered for sale (Section Other ( P _ )—
7044 Business and Professions Code) ® ,1 8-83
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 PERMIT FEE (Sub Total) J
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the TOTAL FEE �f
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring and
hereb authorize representat es his County to enter upon
t a e me coned pro t r i specct/ion purposes SEE REVERSE FOR EXPLANATORY LANGUAGE i
Signature of Permittee Date