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HomeMy Public PortalAbout4859AGNES AVE_Electrical (4) WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O ` I hereby affirm that I have a certificate of consent to self cE 806G insure, or a certificate of Workers' Cbmpensatibn Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS 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. & P Is EACH EACH NO. FEE ADDRESS ❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. 7W $ — $ LOCALITY ���� tion department. Multi-family Sq. Ft. NEAREST Residential Swimming Pools CROSS ST. Date Applicant OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MA Total No. Additional IL COMPENSATION INSURANCE ADDRESS .3,ir (This section need not be completed if the work involved by First 20 CITY A ()�/I'a1 Tel. No. 32j I 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 not employ any person in any manner so as to become subject to the Workers'Com ensati L ws. Lighting Fixtures First 20 ADDRESS Additional DateApplicant Total No. CITY Tel. No. NOTICE TO APPLICANT: If, after making is Certificate of Fixed Appliances Not Over 1 HP PERMIT Exemption, you should become subject to the Workers' Range— Heater—D.W. _ APPLICATION d16�-1 c— Compensation provisions of the Labor Code, you must forth- Oven _ Dryer —W.M.— ADDRESS ©. with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. Hood — Fan —Other_ CITY L/1 n?� Tel. No, 33S--.S-i 7� LICENSED CONTRACTORS DECLARATION LICENSE OR U I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. /5 l3 Class. REG. NUMBER (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRP&I-WO. y'�U PR SSED Y and Professions Code, and my license is in full force and effect. f O_ -7/3 /l Size &Type HP, KW, KVA, or KVAR 0 License Numb e � Lir. Class C, Up to 1 Incl. FINAL U t Over 1 to 10 Incl. DATE 0 VALIDATION Contractor U91te Over 10 to 50 Incl. F1f I•'• I am exempt u er Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 D_ Services, Swbd., MCC & Panelboards Z Date: 0- 200 Amp. Under 600 V Z Signature 201 - 1000 Amp. Under 600 V ❑ Exemption for Reg. Mainz. Elect. Over 1000 Amp. or Over 600 V � SINGLE FAMILY �. HOME OWNER-BUILDER DECLARATION Temp. Power Pole & Appurtenances r a ACCTo I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit 118.�tl Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits Professions Code): 1 ITEMS Conduits&Conductors❑ I, as owner of the property, will do the work and the Misc. TOTAL �, �yy a, .u� structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ Business and Professions Code): ► CHECK 118.50 CONSTRUCTION LENDING AGENCY �.HANGE o()�{ I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). PLAN CHECKING FEE l� Q 00()3- 1 11/14!89 Lender's Name S�11 6797 1 PM120-5 PERMIT ISSUING FEE lVJ 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 the albo e-mentioned ro erty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Jermittee Date ©s