HomeMy Public PortalAbout4926AGNES AVE_Electrical (8) NORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
' y ffirm that'l have a certificate of consent to self CE-806G
i- ora certificate of Workers' Compensation Insurance, . COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy.thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS
Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ — $ LOCALITY
L- Ot
tion department. Multi-family Sq. Ft. — 'NEAREST
Residegtiol Swimming Pools CROSS ST. r!�
Date Applicant \ OWNER OR IA,
FIRM NAME I ,r C/ n />
{ /�Il /[/
CERTIFICATE OF EXEMPTION FROM WORKERS' MAlL
Outlets: Ret r�Light � Sw._
COMPENSATION INSURANCE �d ADDRESS
(This section need not be completed if the work involved by First 20 � CITY
the permit is for one hundred dollars ($100)or less.) Total No. Additional Tel. Na
I certifythat in the performance of the work for which this PLAN CHECK
P 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 C
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT O ��
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
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood — Fan _Other_ CITY Tel. No.
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, PRO S D BY
and Professions Code, and my license is in full force and effect. Power Apparatus& Large Appliances
Size & Type HP, KW, KVA, or KVAR'
lV '®
License Number Lic. Class Up to 1 Incl.
FINAL
DATE
Contractor Date Over 1 to 10 Incl. - VALIDA
Over 10 to 50 Incl. F ILW'AL
❑ I am exempt under Sec. Over 50 to 100 Inc. k1l 2„a 31AI
B.&P.C. for this reason Over 100 rVV1jd& 1#i;o�o 0 0�0 2
�
Services, Swbd., MCC & Panelboards * o•o 41L3 5
Date: 0 - 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V '0 0 o 4 4,3 5 5
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V 1,2 .1 0784
SINGLE FAMILY Temp. Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code):
(
1Z I, as owner of the property, will do the work and the Misc. Conduits& Conductors
`
' 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 o
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 abe v ' entioned property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date