HomeMy Public PortalAbout4835AGNES AVE_Electrical (9) WORKERS'COMPENSATIONDECLARATION CE-806G (2-80) APPLICATION FOR ELECTRICAL PERMIT
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'Com ensation Insurance,or
a o;erfificopy thereof(Sec. 3800, )
� -7 E FOR APPLICANT TO FILL IN JOB 4(83;t)
(lyn�
PoliCpf EACH NO. FEE ADDRESS F� V3
❑ L
New Residential Bldgs.&Pools
Certified copy is hereby furn' h �U v 1 &2-Famil S Ft. $ — $ LOCALITYY. qMulti-family Sq. Ft. NEAREST
Certified copy is filed wit the g inspection CROSS ST
Residential Swimmirig Pools
de artmen OWNER O
FIRM NA
Date i iplicant Outlets: Rec.—Light Sw. ADDRE
First 20 S
CERTIFICATE OF EXEMPTION FROM WOR S'
COMPENSATION INSURANCE Total No. Additional CIT Tel No.
y
PLAN CEJECK d
(This section need not be completed if the work involved APPLICA T O
by the permit is for one hundred dollars ($100) or less.) Lighting Fixtures First 20 ADDRESS V
` Total No.
Additional Cc
I certify that in the performance of the work for which thisCITY Tel No. 0
Fixed Appliances Not Over 1 HP
i permit is issued, I shall not employ any person in any manner PERMIT
I so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLIC W
Oven _ Dryer_W.M. ADDRE' N
To — FAU _W.H. Z
Date Applicant P . / ,�
Hood _ Fan _Other_ CIT L//k ` Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond. LICENSE O
Exemption, you should become subject to the Workers' REG. NUM Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PR SS Y
with comply with such provisions or this permit shall be
deemed revoked. Size&Type HP, KW, KVA,or KVAR / C_
Up to 1 Incl: - �
FINAL
/ /-
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl, DATE VALIDATION
Over 10 to 50 Incl.
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section-7000) of Division 3 of the Busi- Over 100 BY
ness and Professions Code, and my license is in full force and
effect. Services
Lic e Numb r �Lic.Classv0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Con -a t to Over 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp. Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign with One Branch Circuit
License Law for the following reason (Section 7031.5, Busi- Additional Sign Branch Circuits
ness and Professions Code): o 1 7 4 6 A
Misc.Conduits&Conductors
0 I, as owner of the property, will do the work and the Other (See Complete Fee Schedule)— ,0 0 0 0 o 2
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 3 2 Q
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency '0 0 o 3 2 0 0 E
for the performance of t e work for which this permit is PERMIT FEE (Sub-Total)
issued (Sec. 3097,C .).
Lender's Name 0,29-81
PLAN CHECKING FEE (One-Fourth Permit Feel
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE
above information ico rect.I agree to comply with all County
ordinances and State aws regulating Electrical wiring, and
hereby au or repre entatives of this County to enter upon
the abov ent operty for inspectio purpose .
SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of ermittee Date V