HomeMy Public PortalAbout4812 AGNES AVE_Electrical_5/9/1989_outlets and fixtures `r
t Y.iaRKERS COMPENSATION DECLARATION CE 606G 10�a1 APPLICATION FOR ELECTRICAL PERMIT f
I hereby affirm that I have a certificate of consent to self insure k
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES r BUILDING AND SAFETY
copy thererf(Sec 3800 Lab C) fl
Policy No " Company + FOR APPLICANT TO FILL INF r JOB
S r
Certified copy is hereby furnished i r New Residential Bldgs &Pools EACH NO FEE > a ESS '7D�v' $
Certified copy is filed with the county building inspection 1 &2 Family Sq Ft $ — $ LOCALITY h
department r Multi family Sq FtNEAREST
a CROSS ST
Date Applicant t Residential Swimming Pools ` CROSS OR
i I I F / } _ FIRM NAME Yv
f} f CERTIFICATE OF EXEMPTION FROM WORKERS ` { MAIL
a COMPENSATION INSURANCE Outlets Rao Light _Sw ADDRESS
(This section need not be completed If the work Involved by the i First 20
I certify that in the performance of the work for which this permit ,PLAN CHECK
,Is issued I shall note employ, any person in any manner so as to APPLICANT
become subject to the Workers Compensation Laws Lighting Fixtures First 20 ' ADDRESS ,
e Cliv
f iiTotal No AdditionalDate Applicant } CITY r . Tel No
Fixed Appliances Not Over 1 HP PERMIT
w NOTICE TO APPLICANT If after making this Certificate of .�
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW APPLICANT r
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 _ WH
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
CITY Tel No
I hereby affirm that I am licensed under provisions o?Chapter 9 Dlsp — Room Air Cond LIPENSE OR
(commencing with Section 7000)of Division 3 of the Business and EG NUMBER Class
Professions Code and my license is in full force and effect I DISTRICT NO P CES D
Power Apparatus&Large Appliances + p � �
f x
Size&Type HP KW KVA or KVAR C
License Number Lic Class Up to 1 Incl FINAL 0
t Over 1 to 10 Incl TE VA ATION/ C
Contractor Date r t Over 10 to 50 Incl
FINA
M�Jvv
El I am exempt under Sec r Over 50 to 100 Inc 15
LLJ
B&P C for this reason ' Over 100
Services Swbd MCC&Panelboards N
Z
Date 0 200 Amp Under 600 V r
Signature a 201 1000 Amp Under 600 V
Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect a
— SINGLE FAMILY ' Temp Power Pole& Appurtenances f
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuits }
for the following reason(Section 7031 5 Business and Professions g
q 4
Code) + C
/ Misc Conduits&Conductors
S-1-1
L`� I as owner of the property well do the work and the structure ' TIS j
is not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) +
t and Professions Code) ' ® ,
i CONSTRUCTION LENDING AGENCY w . ( ter 1579
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) J � F
Civ C) 1-
PLAN
PLAN CHECKING FEE I
� Lenders Name i 0,!et
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and state that the above TOTAL FEE J
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
property for inspec n urppgposes '
��(����Q�l+r/ � � �� SEE REVERSE FOR EXPLANATORY LANGUAGE o �
4 i
Signature of Permittee ate
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