The URL can be used to link to this page

Home My Public Portal About5112AGNES AVE_Electrical (2) WORKERS CpMPENSATION DECLARATION 63 CE 8 ` < CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certifkcate of consent to self COUNTY OF LOS ANGELES / L BUILDING AND SAFETY insure or a certificate of Workers Compensation Insurance or ` a certified copy ther�f_(S� 3800 Lab C) CO �� i FOR APPLICANT TO FILL IN ,JOB � �;�e,eby Company New Residential Bldgs & of EACH NO FEE ADDRESS / / �.Gf3Q� furnished 1 &2 Family Scl Ft $ — $ LOCALITY 1 fc26A0 — NEAREST ❑ Certified copy is filed with the cou ty uddm ms ct�on Multi family Scl Ft CROSS ST department� Reside tial Swimming Pools OWNER OR �,'� �(7 i FIRM NAME r Date.L� Applicant utlets Rec_Light Sw AMAIL DDRESS cJ First 20 CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY Tel No COMPENSATION INSURANCE _ PLAN C K } APPLICANT 0- (This (This section need not be completed if the work involvedLighting Fixtures 'First 20 U by the permit is for one hundred dollars ($100) or less) Additional ADDRESS Total No cc I certify that in the performance of the work for which this CITY Tel No Q Fixed Appliances Not Over 1 HP permit is issued I shall not employ any person in any manner PERMIT so as to become subject to the Workers Compensation Laws Range_ Heater_D W APPLICANT Ud IJ Oven _ Dryer_W M ADDRESS N Date Applicant Top _ FAU _W HCITYTel No lS� Z Hood _ Fan _Other_ .E NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE OR Exemption , you should become subject ,to the Workers REG NUMBER Class Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PROCES ED !LY with comply with such provisions or this permit shall be deemed revoked _ Size&Type HP KW KVA or KVAR // Up to 1 Incl �J - Over 1 to 10 Incl FINAL S r pCc�` ®rY LICENSED CONTRACTORS DECLARATION DATE _ VALIDATION Over 10 to 50 Incl I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL 9 (commencing with Section 7000) of Division 3 of the Busi Over 100 BY ness and Professions Qode andf�y license is in full force and effect q-'P Services 1 0 200 Amp Under 600 V i p� License Numb Lac Class 201 1000 Amp Under 600 V �� S Contractor Date %'`/J_� Over 1000 Amp or Over 600 V JJJ G � I HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances I I hereby affirm that I am exempt from the Contractor s Sign with One Branch Circuit License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits ness and Professions Code) Misc Conduits&Conductors - 2346.4A J as owner othe property will do the work and the _ ElI of ll h Other (See Complete Fee Schedule)— structure is not intended or offered for sale (Section # 0 0 0 0 0 2 7044 Business and Professions Code) 1 2 0 06 9 1 0 ` CONSTRUCTION LENDING AGENCY] 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is PERMIT FEE (Sub Total) 4 o�0 0 69 1 0 czi issued (Sec 3097 Civ C) �d Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) 03.31 —82 Lender s Address PERMIT ISSUING FEE I certify that I have read this application and state that the TOTAL FEE 116Jabove information is correct I agree to comply with all County V ordinances and State laws regulating Electrical wiring and hereby au one rresentatives f this County to enter upon the ab( a ZonedepI pert mspecUon purposes 31/ 17SEE REVERSE FOR EXPLANATORY LANGUAGE ignatu Permittee Date