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HomeMy Public PortalAbout4833, 4825AGNES AVE_Electrical (11) • ''~WORKERS COMPENSATION DECLARATION 63 CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT CE 8 I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY insure or a certificate of Workers Compensation Insurance or t a certified copy thereof(Sec 3800 Lab C) FOR APPLICANT TO FILL IN ,JOB 1 Policy No Company New Residential Bldgs &Pools EACH NO FEE ADDRESS 3 J A ❑ Certified copy is hereby furnished 1 &2 Family Sq Ft $ — $ LOCALITY ❑ It Multifamily Sq Ft — NEAREST Certified copy is filed with the county building inspectioni CROSS ST r department Residential Swimming Pools t OWNER OR e I i NAV IRM NAME Q — Date Applicant Outlets Rec_Light Sw DDRESS I First 20 IM 0 CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY Tel No COMPENSATION INSURANCE PLAN CHECK } APPLICANT CL (This section need not be completed if the work involved 0 by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS V Total No Additional I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No O permit is issued I shall not employ any person in any manner i PERMIT so as to become subject to the Workers Compensation Laws Range_Heater D W APPLICANT W I417 Oven _ Dryer_W M ADDRESS Z 1` X Date Applicant 11. Top _ FAU _W H CITY Tel No '\ Hood _ Fan _Other_ NOTICE TO APPLICANT If after making this Certificate of Disp — Room Air Cond_ LICENSE OR Exemption you should become subject to the Workers REG NUMBER Class Compensation provisions of the Labor Code you must forth Power Apparatus&Large Appliances DISTRICT NO PROCESSED BY with comply with such provisions or this permit shall be deemed revoked Size&Type HP KW KVA or KVAR © p- i Up to 1 Incl � d FINAL LICENSED CONTRACTORS DECLARATION ` A22-- Over 1 to 10 Incl DATE VALIDATION Over 10 to 50 Incl t I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FIN 9 (commencing with Section 7000)of Division 3 of the Busi Over 100 ness and Professions Code and my license is in full force and effect Services r License Number Lic Class 0 200 Amp Under 600 V 201 1000 Amp Under 600 V Contractor Date Over 1000 Amp or Over 600 V HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits ;95 1 3 2 A ness and Professions Code) # o o l0 0 0 2 Misc Conduits&Conductors I as owner of the property will do the work and the Other(See Complete Fee Schedule)— 2 e i 2 8 5 structure is not intended or offered for sale (Section o •7044 Business and Professions Code) i o • 0 2 5 C CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency F for the, performance of the work for which this permit isPERMIT FEE (Sub Total) 0 7 2 3—8 2 issued(Sec 3097 Civ C) i Lender s Name PLAN CHECKING FEE (One Fourth Permit fee) i e i _ Lender s Address l PERMIT ISSUING FEE y I certify t I have read this application and state that the TOTAL FEE above i orm ton is correct I agree to comply with all County ordma c72 50 es an State laws regulating Electrical wiring and hereb auth rize epresentatives of this County to enter upon t the abve m do d property for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE f Signature i ` Date i