HomeMy Public PortalAbout4812 AGNES AVE_Electrical_4/18/1990_electric panelboard F
WORKERS COMPENSATION DECLARATION CE 806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self Insure CE ao6G
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copv thereof(Sec 3800 Lab C) '
Policy No r Company FOR APPLICANT TO FILL IN., JOB r �/ n t+
ADDRESS /� V
Certified copy,s hereby furnished c s New Residential Bldgs &Pools EACH NO FEE
Certified copy is filed with the county building inspection
1 &2 Family Sq Ft $ — $ LOCALITY {
'department ' t t Multi family Sq Ft 1 NEAREST
CROSS ST 240
Date , Applicant Residential Swimming Pools ° OWNER OR t +
+� t �' FIRM NAME 1a CL
i CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec—Light —Sw ><{ F� i MAIL G
to w COMPENSATION INSURANCE a ^� s �, 4 f ADDRESS S a In A0--
(This section need)not be completed if the work involved by the First 20 S � f /
permit is for one hundred dollars($100)or less) Total No Additional 4 P CITY 2Ile, ✓ Tel No
1 certify that in the performance of the work for which this permit t �� t t APPLICANT CHECK t '
is issued I shall not employ any person in any manner so as to �+ '
become subject to the Workers rkers Compensation Laws Lighting Fixtures First 20 ADDRESS
w t
a , Additional
Total No CITY ; I Tel No ,
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after.,making this Certificate of APPLICANT
+ Exemption you should become subject to the Workers Compensation Range_ Heater DW _
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 _ y
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LICENSED CONTRACTORS DECLARATION i Hood — Fan _ Other_ CITY Tel No
I hereby affirm that I am licensed under provisionsyof Chapter 9 Dlsp — Room Air Cond LICENSE OR Class
(commencing with Section 7000)of Division 3 of the Business and , REG NUMBER
Professions Code and my license is in full force and effect Power Apparatus&Large Appliances DISTRICT NO PRO S D BY }.
t, iL
Size&Type HP KW KVA or KVAR U
License NumberLic Class Up to 1 Incl FINAL
r Over 1 to 10 Incl DATE �> +�
Contractor Date ` VALIDATION O
❑ Over 10 to 50 Incl _ ^
I am exempt under Sec Over 50 to 100 Inc s FINAL
r d i
B&PC for this reason o Over 100 JP112= N
Services Swbd MCC&Panelboards E t r Z
Date 0 200 Amp Under 600 V +
i
Signature 201 1000 Amp Under 600 V
v
Exemption for Reg Maint Elect + Over 1000 Amp It or Over 600 V
SINGLE FAMILY Temp Power Pole& Appurtenances j, a 2
HOME OWNER BUILDER DECLARATION '
I hereby affirm that I am exempt from the Contractors License Law , Sign with One Branch Circuit s
for the following reason(Section 7031 5 Business and Professions r Additional Sign Branch Circuits - A(CT a
Cod ) � 3307 5 � 31 01
I as owner of the property will do the work and the structure Misc Conduits ti& Conductors , 1 ITEMS'
,s not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule),_
and Professions Code) ® '~ ) TOTAL" 9$m 00
CONSTRUCTION LENDING AGENCY K CHECK 4 31.00
1 hereby affirm that ere m a construct,. ding agency for the r�
performance of thew k for which this p it is issued(Sec 3097 PERMIT FEE �" "'," (Sub Total)! I t i CHANGE 0V 5
Civ C) a �
PLAN CHECKING FEE �Q�]p-0001 b 4/18/9'0 y
Lenders Name r t ,
PERMIT ISSUING FEE
Lenders Address a a 0167 1' AM 9 29
I certify that I W
, tion and state that the above TOTAL FEE,
information is cm with allCounty ordinances
and State'lawsal %ng and hereby authorize tnt t,vesenter n the abo mentioneda0 or, +
� SEE REVERSE FOR EXPLANATORY LANGUAGE
4
f t
ature of Permittee DaJ6t K