HomeMy Public PortalAbout4849AGNES AVE_Electrical (4) WORKERS COMPENSATION DECLARATION 76A663 10/81
1 affirm that I have a certificate of consent to self Insure CE 806G APPLICATION FOR ELECTRICAL PERMIT {�
or ificate of Workers Compensation Insurance or a certified 1 COUNTY OF LOS ANGELES BUILDING AND SAFETY Ll
C( of(Sec 3800 Lab C) .rA F. �
yo`LRS Company /Fi7� PLWO FOR APPLICANT TO FILL IN s JOB
Certified copy is hereby furnished New Residential Bldgs &Pools EACH NO FEE
ADDRESS
Certified copy Is filed with the county building Inspection 1 & 2 Family Sq Ft $ — $ LOCALITY
department r Multi family Sq Ft NEAREST
CROSS ST
Date u
AppllCant_� j Residential Swimming Pools
� „ OWNEROR
^� NI LI
�J NAME
CERTIFICATE OF EXEMPTION FROM WOy FIRM S iMAIL
Outlets Rec—Light_ Sw —
COMPENSATION INSURANCE ADDRESS � ✓�
(This section need not be completed If the work Involved by the First 20
permit Is for one hundred dollars($100)or less) Total No Additional CITY Bq� 'C .r Tel No
I r it PLAN CHECK
I certify that in the performance of the work for which this permit + 1APPUCANT i
Is Issued I shall not employ any person in any manner so as to
become subject to the Workers Compensation iLaws Lighting Fixtures ' First 20 ADDRESS
w / � Additional
{ Total No CITY Tel No '
Date Applicant
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
It
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW _ APPLICANT
provisions of the Labor Code you must forthwith comply with such rt Oven _ Dryer_ W M _ ADDRESS TiJN nf2
provisions or this permit shall be deemed revoked Q
LICENSED CONTRACTORS DECLARATION Top__ FAU ? W H CITY G(T Tel No C9(o
Hood — Fan Other a
I hereby affirm that I°am licensed under provisions of Chapter 9 Dis — Room Air Cond LICENSE B (1
(commencing with Section 7000)of Division 3 of the Business and p REG NUMBER Z a 3 CI gg C�ZO
Professions Code and 3 my license is In full force and effect Power Apparatus& Large Appliances NO,DISTRICT 1K PRO D BY
10Size&Type HP KW KVA or KVARL12Q 8
License Number ' Lic Class C—""O Up to 1 Incl FINAL
CH"
Over 1 to 10 Incl DATE �t0l
Contractor6� COY! � Date VALIDATION
❑ y Over 10 to 50 Incl ' FINAL'
I am exempt under Sec Over 50 to 100 Inc BY U
B&P C for this reason Over 100 N
Services Swbd MCC&Panelboards Z
Date 1 0 200 Amp Under 600 V r
Signature 201 1000 Amp Under 600 V
❑ Over 1000 Amp or Over 600 V W
Exemption for Reg Maint Elect ti a f
SINGLE FAMILY Temp Power Pole&Appurtenances ACCT a
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit Tin ^ 17
I hereby affirm that I am exempt from the Contractors License Law Additional SI n Branch Circuits 3307 y
50
f odh following reason(Section 7031 5 Business and Professions g 1 IT hi
eor
TOTAL 1`-�+ r
.50
I as owner of the property well do the work and the structure Mlsc Conduits&Conductors TO
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) _ ® � 17 50and Professions Code) ' s .V 1 M
i f
CONSTRUCTION LENDING AGENCY CWGE ' Ws
I hereby affirm that there Is a construction lending agency for the p ti
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub}Total) L
Civ C) d 0000—CMI 9113/89
Lenders Name PLAN CHECKING FEE r y c 5674 1 t AM 9 0,4
r PERMIT ISSUING FEE 106
Lenders Address I I
I certify that I have read this application and state that the above TOTAL FEE (5
i information Is correct I agree to comply with all County ordinances
i
and State laws regulating Electrical wiring and hereby authorize
representatives of this County to enter upon the above mentioned
property for Inspection purposes ' R
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature of erm a Date