HomeMy Public PortalAbout4822 AGNES AVE_Electrical_10/22/1951_21616 elect panel WORKERS COMPENSATION DECLARATION 20 OD19 DPW 3/87 -� APPLICATION FOR ELk7RICALI PERMIT O
I hereby affirm that I have a certificate of consent to self CE 806G
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or a certified copy thereof (Sec 3800 Lob C )
Policy No Company FOR APPLICANT TO FILL IN JOB /�CjeS
Certified copy is hereby furnished _ New Residential Bldgs & Pools EACH NO FEE ADDRESS %2` / e—
Certified copy is filed with the county building inspec 1 &2 Family Sq Ft $ — $ LOCALITY`��Yh 1..
1 i e (2-1
tion department it Multi family Sq Ft — NEAREST
CROSS ST D (�T S
Residential Swimming Pools OWNER OR
Date Applicant FIRM NA ��
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Li ht Sw_ MAIL
COMPENSATION INSURANCE g ADDRESS `7 f7 e' UG.
(This section need not be completed if the work involved by First 20
PLAN CHECK
I certify that in he performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS
Total No Additional I
Date Applicant CITY Tel No
NOTICE TO APPLICANT If )after making this Certificate of Fixed Appliances Not Over 1 HP > PERMIT
Exemption you should become subject to the Workers Range— Heater—D W _ APPLICATION
Compensation provisions of the Labor Code you must forth Oven — Dryer —W M — ADDRESS
with comply with such provisions or this permit shall be Top —/FAU —W H —
deemed revoked Hood — Fan —Other_ I CITY r Tel No
LICENSED CONTRACTORS DECLARATION i Disp — Room Air Cond — LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER Class
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NOP �S/SE'D BY >_d
and Professions Code and my license is in full force and effect f� G%Z�L
Size&Type HP KW KVA or KVAR �QO 0
License Number Lic Class Up to 1 Incl FINAL U
Contractor Date Over 1 to 10 Incl l DATE 2 2 VALIDATION cr
aOver 10 to 50 Incl i FINAL -2 V
I am exempt under Sec Over 50 to 100 Inc BY W
B&P C for this reason Over 100 Il
Date Services Swbd M/C�PR lb-o�fds Z
0 200 Amp finder 6bbT/—� —
Signature 201 1000 Amp Under c00 V
QExemption for Reg Maint Elect Over 1000 Amp or Over 600 V
SINGLE FAMILY Tem Power Pole&Appurtenances y
HOME OWNER BUILDER DECLARATION P Ci E
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor sLicense -v .vim
Law for the following reason (Section 7031 5 Business and Additional Sign Branch C+rcuits
Profe ons Code) i z z iw
i as owner of the property will do the work and the Misc Corrf i tsA Conductors s
( Other See Complete Fee Schedule , I il_
structure is not intended or offered for sale Section 7044 ( P )—
Business M-
and Professions Code)
CONSTRUCTION LENDING AGENCY
1 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)
(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 .4-4631
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring and
hereby authorize presentatives of this County to enter upon
t eabove men ed prop ty fo inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
ignatur of Permittee Date ` ®s