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Home My Public Portal About4859AGNES AVE_Electrical (3) WORKERS' COMPENSATION DECLARATION 76A66vDPwaia7 APPLICATION FOR ELECTRICAL PERMIT 2 O ` I hereby affirm that I have a certificate of consent to self �ac insure, or a certificate of Workers' ComperisaCE eo tibn Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WO or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. LOCALITY DO $ _ $ � � G• tion department. Multi-family Sq. Ft. NEAREST Residential Swimming Pools CROSS ST. OWNER OR Date Applicant FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL ��_� Outlets: Rec Light Sw._ !N/ COMPENSATION INSURANCE First 20 ADDRESS Au (This section need not be completed if the work involved by Total No. Additional CITY a�rU � Tel. N. c7l / 3ZI the permit is for one hundred dollars($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit is issued, I shall notemploy any person in any ma ner so as to be m subject to the Workers'Com ensati L ws. Lighting Fixtures First 20 ADDRESS Additional Total + C Total No. CITY Tel. No. Date 11 d Applicant Fixed Appliances Not Over 1 HP PERMIT //-- NOTICE TO APPLICANT: If, after making t is Certificate of APPLICATION LG Exemption, you should become subject to the Workers' Range— Heater—D.W. — Compensation provisions of the Labor Code, you must forth- Oven — Dryer —W.M.— ADDRESS 7j } with comply with such provisions or this permit shall be To _ FAU —W.H. — deemed revoked. Hood — Fan —Other— CITY C'pv�l�1�, Tel. No. 2 Sal LICENSED CONTRACTORS DECLARATION LICENSE OR u� 3 6-0I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER / Class. (commencing with Section 7000)of Division 3 of the Business Power Apparatus & Large Appliances DISTR CT NO. PR ESSED BY >- and Professions Code,and my license is in full force and effect. a- i C-0 .'Z/�\ Size &Type HP, KW, KVA, or KVAR O License Numbe 7� Lic. Class Up to 1 Incl. FINAL Over 1 to 10 Incl. DATE Cc /°d VALIDATION Contractor ate❑ Over 10 to 50 Incl. U F- FINAL I am exempt under Sec. Over 50 to 100 Inc. BY LU B.&P.C. for this reason Over 100 A 13- Services, lServices, Swbd., MCC& Panelboards Z Date: 0-200 Amp. Under 600 V V — • Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V i r j SINGLE FAMILY Temp. Power Pole &Appurtenances AG+. HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit GT°a 4 I hereby affirm that I am exempt from the Contractor's License ,.� Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits 3307 113.5 Professions Code): 1 ITEMS ❑ 1, as owner of the property, will do the work and the Misc. Conduits &Conductors structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , TOTAL 1 IS .50 Business and Professions Code). CHE 11$°5I CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for CHANE °0 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE JD 0000—owl 11/14/`�l Lender's Name PERMIT ISSUING FEE SD 6798 1 PM12:52 Lender's Address 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 thea ove- ntione p operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature Permittee Date ©: