HomeMy Public PortalAbout4904AGNES AVE_Electrical (3) DECLARATI
20 0019
WORKER I haveCOMPENSATION
ate of consent to 76AS63 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT
76A663
I hereby affirm that I have a certificate of consent to self insure
or a certificate of Worker s Compensation Insurance or a certified COUNTY OF LOS ANGELES DEPT OF PUBLIC WORKS BUILDING AND SAFETY DIV
copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS
F1e9
Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE
_ $ $ LOCALITY i
Certified copy is filed with the county budding inspection 1&2 Family Sq Ft NEAREST
department Multifamily Sq Ft — CROSS ST
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Reo —LI ht Sw OWNER OR
COMPENSATION INSURANCE g FIRM NAME
f
(This section need not be completed If the work involved by the First 20 MAILTotal No Additional ADDRESS
permit is for one hundred dollars($100)or less)
I certify that in the performance of the work for which this permit CITY Tel No
Is issued I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPLICANT
Total No Additional ADDRESS
Date ` Applicant 1 ' " k
NOTICE TO APPLICANT If after making this Certificate of RESIDENTIAL APPLIANCES NOT OVER 3 HP CIT. Tel No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS ' 1
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 InclCITY Tel No >_(commencing with Section 7000) of Division 3 of the Business and d
Professions Code and my license is in full force and effect Over 10 to 50 Incl
LICENSE
Over 50 to 100 Incl REGNUM ER y Class V
License Number t 4 LIC Class ^� Over 100 DISTRICT NO PROCESSED BY J
Services Swbd MCC&Panelboards ' LL
f
Contractor Date 0 399 Amp Under 600 V DATE }
r_1400 1000 Amp Under 600V II
I am exempt under Sec Over 1000 Am or Over 600 V VALIDATION
Amp BY AL O
B&P C for this reason BRANCH CIRCUIT FEES
Date 15A or 20A 120V Lighting or Recept CL
J 1 To 10 Branch Circuits =� W
Signature 11 To 40 Branch Circ 'is f
❑ 41 Or More BranchlClrcuits Ats
"'Exemption for Reg Maint Elect 15A 20A 208V To 277V Lighting Br Circuits y
SINGLE FAMILY Temp Power Pole&Appurtenances dyrig vL
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit lei�rr8
I hereby affirm that I am exempt from the Contractors License Law " 9
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits , C
Code) I tMS
❑ I as owner of the property will do the work and the structure Mlsc Conduits&Conductors
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) IWO
and Professions Code) , bog
0
CONSTRUCTION LENDING AGENCY ff �+ "
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total)
Civ C)
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE
Lender s Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the 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 mentioned property
for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
r
SIGNATURE OF PERMITTEE DATE