HomeMy Public PortalAbout4851AGNES AVE_Electrical WORKERS COMPENSATION DECLARATION 200019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT Q
ereby ��
affirm that I have a certificate of consent to self teo6 r
sure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS
or a certified copy thereof (Sec 3800 Lab C ) t
Policy No Company ' FOR APPLICANT TO FILL IN JOB Lf�/-
❑Certified copy is hereby furnished New Residential Bldgs &Pools� EACH NO FEE ADDRESS J
❑Certified copy is filed with the county building mspec LO
1 &2 Family Sq Ft---6�-`= $ — $ NEARESCALIT �� G
tion department Multifamily Sq Ft — NEAREST
\ Residential Swimming Pools OWNER CROSS SOR w_
Date Applicant FIRM NAME O �'•�7C/
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec Light Sw_ AMAIL
DDRESS c3i�
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by Total NoCITY el No
the permit is for one hundred dollars($100)or less) ) Additional ��� Z-�
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 Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers Compen ation Laws
Additional
I_8- Total No CITY Tel No
Date Applicant 9 Fixed Appliances Not Over 1 HP ; ( PERMIT
NOTICE TO APPLICANT If after making thi ertificate of APPLICATION
Exemption you should become subject o the Workers Range— Heater—D W — /lr
Compensation provisions of the Labor Code you must forth Oven — Dryer —W M — ADDRESS P o-
with comply with such provisions or this permit shall be Top , — FAU —W H --
deemed revoked Hood — Fan —Other— CITY �/� Tel No� �]
LICENSED CONTRACTORS DECLARATIONLICENSE OR
p Room Air Co
Dis — ndi—
I hereby affirm that I am licensed under provisions of Chapter 9 0 REG NUMBER �S� 3 Class C1_0
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT NO P ESTE Y � d
and Professions Code and my license is in full force and effect
Size&Type HP KW KVA or KVAR ( O
License Number `�s7 Lic Class C-0 Up to 1 Incl FINAL n U
� `���� Over 1 to 10 Incl DATE rl I VALIDATION �
Contractor aTe Over 10 to 50 Incl FINAL VVV
❑ I am exempt under Sec Over 50 to 100 Inc BY U
LU
B&P C for this reason Over 100 d
Services Swbd MCC&Panelboards ► 0
Date ?
0 200 Amp Under 600 V �
r Signature 201 1000 Amp Under 600 V
Oyer 1000 Amp or Over 600 V
F-1Exemptionfor Reg Maint Elect
SINGLE FAMILY Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch CircuitACCf eA
I hereby affirm that I am exempt from the Contractor s License Add�t�onal Sign Branch Circuits
Law for the following reason (Section 7031 5 Business and g -� 11� c
Professions Code)
. tl
❑ I as owner of the property will do the work and the Misc Conduits&Conductors 1 ITEM �
structure is not intended or offered for sale(Section 7044 Other (See Complete Fee Scheduled PTAL 1 IS®SID
Business and Professions Code)
CONSTRUCTION LENDING AGENCY CHECK 11°a� I
I hereby affirm that there is a construction lending agency for tHANGE I0
the performance of the work for which this permit is issued PERMIT FEE (Sub Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE l�
Lender s Name 0000-0001 11I1'rf"'5
ry
Lender s Address PERMIT ISSUING FEE It�D 6794 1 PM12:a1
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 laws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
the above ment ned proper y for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
9 Os
Signature of P rmittee Date