HomeMy Public PortalAbout5136AGNES AVE_Electrical (6) WORKERS'COMPENSATION DECLARATION 76A66eovw3ie7 APPLICATION FOR ELECTRICAL PERMIT O
I hereby affirm that I have a certificate of consent to self CE 806G
insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB �I374, �
El 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
tion department. Multi-family Sq. Ft. NEAREST
Date Applicant Residential Swimming Pools CROSSOWNEST. 7M I LD1WAI
CERTIFICATE OF EXEMPTION FROM WORKERS' � 3 FIRM NAME 1/ICK 7
Outlets: Rec Light Sw. ADDRESS
COMPENSATION INSURANCE o ��3� �bnl�`7
First 20
(This section need not be completed if the work involved by Total No. 15 Additional CITY T�/d) Tel. No.28b 1i/
the permit is for one hundred dollars (5100)or less.) PLAN CHECK rr�/�-�-
I certify that in the performance of the work for which this APPLICANT ���U (�E���Gry
permit is issued, I shall not employ any person in any manner -7 AZOA
so as to become subject to the Workers'Compensation Lows. Lighting Fixtures First 20 Q � 0 ADDRESS 5� � 7
r i Additional � �b
ME</ �f�tlE�MG Total No. 5 CITY TV�' Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT n
NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION ��V eV�t-OP1M6AJT_
Exemption, you should become subject to the Workers' Range— Heater—D.W. — n
Compensation provisions of the Labor Code, you must forth- Oven — Dryer -/—W.M.— ADDRESS 152_'7 AJ A�SPi
with comply with such provisions or this permit shall be Top — FAU W.H. —
deemed revoked. Hood — Fan/]%:Other— CITY 600J %A Tel. No. 501
LICENSED CONTRACTORS DECLARATION LICENSE OR -q/� '
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER l7 Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY >_
and Professions Code,and my license is in full force and effect. D_
3 Size &Type HP, KW, KVA, or KVAR Q
License Number y 0&213 Lic. Class & Up to 1 Incl. FINAL U
1V
ContractorGJ Dwate �Z��-1 I _ Over 1 to 10 Incl. DATE Z _�` L; VALIDATION 0
❑ Over 10 to 50 Incl.
/ F_
/,�B �y FINAL U
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C. for this reason Over 100 d Z
Date: Services, Swbd., MCC & Panelboards Z
0- 200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances
I herebyaffirm that I am exempt from the Contractor's License Sign with One Branch Circuit „
n Branch Circuits p Additional Si
Law for the following reason (Section 7031.5, Business and 9
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ , I "
39 22p
Business and Professions Code). :
CONSTRUCTION LENDING AGENCY :~:�;�r•Fi _
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) :•! i i!7i ,1'l
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name / i '1(_i 0••_;-iri�l
PERMIT ISSUING FEE -` -•
Lender's Address !_ �. 4 •:
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 ove-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Os
S nature'of Per it ee Date