HomeMy Public PortalAbout4818 AGNES AVE_Electrical_12/3/1951_elect panel WORKERS COMPENSATION DECLARATION zoaol9DPW 3/87 oec
APPLICATION FOR ELECTRICAL PERMIT O
'�IYT*p'by affirm that I have a certificate of consent to self c ae�
insure Na certificate of Workers Compensation 1Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or Yertitied 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 /p Aid Aa-S
❑Certified copy is filed with the county building mspec 1 &2 Family Sq Ft $ — $ LOCALITY
tion department l Multifamily Sq Ft NEARECROSS ST
Date , Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw_ MAIL
COMPENSATION INSURANCE First 20 ADDRESS
ed 7
(This section no"not be completed if the work involved by Total No Additional CITY Tel No
the permit is for one hundred dollars ($,100)or less) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers Com a on L ws i g g
Total No
Date Additional CITY Tel No r�� Applicant Fixed Appliances Not Over 1 HP PERMIT3!'�!
NOTICE TO APPLICANT If after making this Certif Range— Heater—D W — APPUCATIO CiC.0
Exemption you should become subject to the vers 9
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 �a�'L �r7i?Vo� Q 3Gf y,
LICENSED CONTRACTORS DECLARATION Dis — Room Air Cond LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 p REG NUMBER .127-3` lel Classe/O
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO PROC SSED 8Y >_
and Professions Code and my license is in full force and effect t �/ I 11
e f / Size&Type HP KW KVA or KVAR JI /;t 0
License Numbery7y,7 Lic Class r Up to 1 Incl FINAL
/y�/ICl �9� ✓�l/ �_y_ 9i Z Over 1 to 10 Incl DATE / / VALIDATION
Contractor Date i O
❑ Over 10 to 50 Incl FINAL
I am exempt under Sec Over 50 to 100 Inc BY W
B&P C for this reason Over 100 tl
Ser d-ioe ards , Z
0 200 Amp Under eV Signature 201 nder 60
❑ 1 Oyer 1000 Amp or Over 600 V
Exemption for Reg Maint EI t
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor s License Sign with One Branch Circuit }
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits r s
Professions Code)
❑ I as owner of the property will do the work and the Misc Conduits&Conductors
structure is not intended or offered for sale(Section 7044 Other (See Complete Fee Schedule)_
Business and Professions Code) , r'- „ ��
CONSTRUCTION LENDING AGENCY Frt�f r
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) 4 T1N�'ti� 1 1
(Sec 3097 Civ C )
PLAN CHECKING FEE 3 (-j✓
Lender shame
r J 1
' � PERMIT ISSUING FEE -
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County
ordinances and State jaws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
the above mentioned property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
t J
Signature of Permittee Date ®�