HomeMy Public PortalAbout4901AGNES AVE_Electrical (3) r W RKERS'COMP)NSATIQN DECLARATION toiet
CE-806 APPLICATION FOR ELECTRICAL PERMIT
herbf affirm that l have a certificate of consent to self CE-806G
insure,or a certi.;icote of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No.7) xS24 Company PT-4-7-E E-1 ,-A FOR APPLICANT TO FILL IN JOBZI
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS ® / r
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY
c l y
NEAREST
tion department. /� bd Multi-family Sq. FT. CROSS ST. —
�-_ G�I7 Residential Swimming Pools OWNER OR •�
Dare Applicant FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ AMAIL
DDRESS '901
COMPENSATION INSURANCE First 20
(This section need not be completed if the work involved by Total No. Additional r CITY7� � r Tel. No. 2 O
the permit is for one hundred dollars ($100)or less.) PLAN CHECK
1 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'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT /1� eQ1
Exemption, you should become subject to the Workers' Range_ Heater—D.W. _ pp
Compensation provisions of the Labor Code, you must forth- Oven — Dryer — W.M.— ADDRESS e U e !V
with comply with such provisions or this permit shall be Top FAU W.H. —
deemed revoked. Hood Fan Other_ ne)
CITY r Tel. No. Cps /
LICENSED CONTRACTORS DECLARATION _
Disp. _ Room Air Cond. LICENSEAj Class.
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER _71
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO. PROCESSED BY
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances cc`� Q.
Lf
?G; Size & Type HP, KW, KVA, or KVAR' JPO O
L/
License Number LIZ L f a/ Lic. Class Up to 1 Incl. FINAL k;
Contractor a L L}-lYld (7 f'—��_ $ Over 1 to 10 Incl. DATE ALIDATION
V r kLiate Over 10 to 50 Incl.
FINAL V
❑ I am exempt under Sec. Over 50 to 100 Inc. BY LU
B.&P.C. for this reason Over 100
Date: Services, Swbd., MCC & Ponelboards 6 9 7.5 A
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V #.o o 0 0 0 2
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. `1 -,o29.00
SINGLE FAMILY Temp. Power Pole& Appurtenances '0,0 - 29,000
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License 0 0(�6 8 7
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code):
❑ Misc. Conduits&Conductors
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ►
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY
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
Lender's Name
- PERMIT ISSUING FEE L v S
Lender's Address /)
I certify that I have read this application and state that the TOTAL FEE V
above information is correct. I agree to on
with all County
ordinances and State laws regulating Electrical wiring,and '
hereby authorize representatives of this County to enter upon
the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
&a, &ati —'5 — 6 —.82
Signature of Permittee Date