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HomeMy Public PortalAbout4926AGNES AVE_Electrical (4) WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT {� IJ 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'Ldig'ANGELES BUILDING AND SAFETY copy thereof(Sec. 3800,Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ���/• /1./�{/7-� �r�— _ ❑ Certified copy is herebyfurnished. EACH NO. FEE ADDRESS (9 /7GOieG New Residential Bldgs. & Pools ❑ Certified copy is filed with the county building inspection 1 & 2-Family,Sq.Ft. $ — $ LOCALITY CCC department. Multi-family Sq.Ft. — NEAREST )o W�R CROSS ST. L Date Applicant Residential Swimming Pools OWNER OR FIRM NAME CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light Sw. MAIL COMPENSATION INSURANCE ADDRESS '(This section need not be completed if.the work involved b the First 20 p by No. Additional PLAN CHECK CITY Tel.No. permit is for one hundred dollars($100)or less.) I certify that in the performance.of the.work for which-this permit 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. CITYTel.No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT N NOTICE JO APPLICANT: If, after making this .Certificate of APPLICANT Exemption,you should become subject to the Workers'Compensation Range_ Heater_ DW-._ provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M._ ADDRESS provisions or this permit shall be deemed revoked.. Top _ FAU _ W.H. _ CITY r Tel.No /�) �(© 9 3 LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ I hereby affirm that.I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR. Class. (commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Professions Code,and my license is,in full force and effect. DISTRICT NO. P ESSED BY Power Apparatus& Large Appliances Size& Type HP, KW,KVA,or KVAR _5 GGA p License Number Lic.Class Up to 1 Incl. FINAL U Over 1 to 10 Incl. DATE /•�_ VALIDATION Q Contractor Date Over 10 to 50 Incl. AA FINAL !�� U ❑ I am exempt under•Sec. Over 50 to 10'0/1�nK�' BY W BAP.C.for this reason Over 10 Lry"" U) Services,S C a ielflboards G O , _ Date: 0 2 Amp.U er 600 V Q Signature 201 - 1 mp.Under 600 V ❑ Over 1000 Amp.or Over 600 V Exemption for Reg.Maint.Elect. SINGLE FAMILY Temp.Power Pole& Appurtenances ACCT R HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �-a °� I hereby affirm that I am exempt from the Contractor's License Law h7 for the following reason (Section 7031.5,Business and Professions ��yy�� Additional Sign Branch Circuits .7.3L Code): I ITENS Misc. Conduits & Conductors TOTAL 6� 0 I,as owner of the property,will do the work and the structure .. is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) t� �n and Professions Code). , CASH 65°60 CONSTRUCTION LENDING AGENCY CKAME °00 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.). M qq PLAN CHECKING FEE _���8 9,��/py� Lender's Name 2329 AM 10301 PERMIT ISSUING FEE 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 nspection purposes. / SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permittee Date