HomeMy Public PortalAbout4901AGNES AVE_Electrical (8) affirm that
COMPENSATION DECLARATION CE-806G 10/81 APPLICATION FOR ELECTRICAL PERMIT
tlsat I have a certifryate of consent to self 7�
nsur ,,.ora 7.6rtif:icotel6f Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY 1u'
or a certifinedd ccyopy%thereof (Sec. 3800, Lab. C.)
Policy No Company FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. EACH NO. FEE ADDRESS 0 N �1/
PY Y New Residential Bldgs. & Pools
LOCALITY
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ C C
tion department. Multi-family Sq. Ft. — NEAREST
CROSS ST. &O Wim. AZU5f} tQ10
Date �,&qJJZ Applicant Residential Swimming Pools OWNER OR p�-
�QQ FIRM NAME (�t►tcr), jo
CER IFICATE OF EXEMPTION FROM W RKERS' Outlets: Recpp_QLight"Sw. �2' MAIL (
COMPENSATION INSURAN
(This section need not be completed if the work involved by First 20 tS ADDRESS
Total No. Additional ) CITY je C Tel. No 3-,'/3D
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'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. II Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over I HP PERMIT
NOTICE TO APPLICANT: If,, after making this Certificate of APPLICANT
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 �Z LV
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood Fan _ Other_ CITY Tel. N �poZ
LICENSED CONTRACTORS DECLARATION LICENSE OR
I 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 DISTRICT NO. PROCESSED BYCL
and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances C)
//�� Size &Type HP, KW, KVA, or KVAR J[ v U
License Number Lic. Class C1 Up to 1 Incl. FINAL yy��
Over 1 to 10 Incl. DATE /V O'
Contractor Date 'O V LIDATION
QOver 10 to 50 Incl. FIN W
I am exemp under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100 Z
Date: Services, Swbd., MCC & Panelboards
0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole 8 Appurtenances ;2 6 7 Q 9 A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License # o o o o a 2
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code):
,I 0 0
4 4 2 5
I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors
o 0 0 4 L�2 5 c�i
structure is not intended or offered for sale (Section Other (See.Complete Fee Schedule)_ oil7044, Business and Professions Code). O 3.20-87
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
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 abovWgientioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
A:_ 3 �
i 'gnature of Permate