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Home My Public Portal About4851AGNES AVE_Electrical (2) 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