HomeMy Public PortalAbout4919AGNES AVE_Electrical (2) WORKERS'COMPENSATION DECLARATION r 76-663 10/81 APPLICA�iON!"FOR ELECTRICAL PERMIT
� . I hereby affirm that I have a certificate of consent to self insure, CE-806G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof (Sec. 3800,Lab. C.)
Policy No. - Company FOR APPLICANT TO FILL IN JOB
❑ ADDRESS 7
Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE
1 & 2-Family,Sq.Ft. $ — $ LOCALITY
Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft.
Date —
Residential Swimming Pools CROSS
Applicant OWNER OR y
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. y MAIL
COMPENSATION INSURANCE �� /Q ADDRESS I /
This section need not be completedFirst 20
( if the work involved b y the Total No. Additional CITY f G 7o.-- Tel.No
permit is for one hundred dollars ($100)or less.)
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
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
Additional
Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT �
Exemption,you should become,subject to the Workers'Compensation Range_ Heater_ D.W. APPLICANT�j __r 70
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer W.M. ADDRESS
t shall be deemed revoked. Top — FAU W.H. —
provisions or LICENSED I CONTRACTORS DECLARATION Hood _ Fan Other— CENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE
(commencing with Section 7000) of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER
ER Class.
Professions Code,and my license is in full force and effect. Power Apparatus& Large.Appliances DISTRICT NO. PROC SSED BY
Size& Type HP,KW,KVA,or KVAR d�� Ll� G��J 0
License Number Lic.Class Up to 1 Incl. FINAL U
Over 1 to 10 Incl. / DATE G�� VALIDATION
Contractor Date Over 10 to 50 Incl. FINAL l U
❑ I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason Over 100 Q.
Service CC& Panelboards / , Z
Date:
p.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& Appurtenances . "t
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit _ A
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits ACCT.
for the following reason (Section 7031.5, Business and Professions -,-
Code): 3307 78.23
_
I,as owner of the property,will do the work and the structure Misc.Conduits& Conductors 1 ITEMS/� ^'
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) yL�T!'IL v
and Professions Code). t L' �r
7-3
CONSTRUCTION LENDING AGENCY - - ---- •-
CHECK 78.23
I hereby affirm that there is a construction lending agency for the CHAWSE ,Qin
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.).
PLAN CHECKING FEE ita —tJ,.w1 '8/20/9Lender's Name PERMIT ISSUING FEE 5111 1 AM 8:27
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
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
ignatur of Permittee Date