HomeMy Public PortalAbout5218AGNES AVE_Electrical (5) � im a ' COMPENSATION DECLARATION 76-663 10/61
I hereby affirrthat
I
m that have 1; certificate of consent to self insure, CE-Bose APPLICATION FOR ELECTRICAL PERMIT
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Poficy No. - Company FOR APPLICANT TO FILL IN JOB
❑ ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.& Pools EACH NO. FEE
$F $ LOCALITY (�.rt3�
S
il
F
2- amy, q. t. — �- �, �
Certified copy is filed with the county building inspection 1 & — NEAREST
department. Multi-family Sq.Ft. CROSS ST. L
Date Applicant
Residential Swimming Pools OWNER OR iJA�
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' � MAIL /yam
COMPENSATION INSURANCE Outlets:Rec Light t 2 75 ' ADDRESS ` A`Sj
This section need not be completed if the work involved by the IL_
////// First 20
( P >f CITY�' Tel.No.
permit is for one hundred dollars($100)or less.) Total No. Additional
I certifythat in the performance of,the work for which this permit PLAN CHECK
P P APPLICANT ,
is issued, I shall not employ any person in any manner so as to
become subject to the orkers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
�— Total No. CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT L�
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W.
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.
LICENSED CONTRACTORS DECLARATIONCITY �/' s Tel. No. j��
Hood Fan Other_
I(commencing with Section 7000) of Division 3 of the Business and hereby affirm that I am licensed under provisions of Chapter 9 LICENSE O Q p
Disp. — Room Air Cond. REG.NUMBER p Class.
Professions Code,and my license is in full force and effect. DISTRICT NO. SED BY
Power Apparatus& Large Appliances
t �=
Size& Type HP,KW,KVA,or KVAR 0-
License Numbe4� ®� Lic. Class 1 r Up to 1 Incl. FINAL
3.—�
Over 10 to 50 Incl.
Over 1 to 10 Incl. DATE VALIDATION
' � �
Contractor Date FIN O
❑
I am exempt under Sec. Over 50 to 100 Inc. W
B.&P.C. for this reaso Over 100 4.
Services,Swbd.,MCC& Panelboards N
Date: 0- 200 Amp.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
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits
for the following reason(Section 7031.5, Business and Professions
Code):
ElMisc.Conduits& Conductors
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) ,
and Professions Code).
CONSTRUCTION LENDING AGENCY ;9 9.2 7 5 A
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) # o o,o o 0 2
Civ.C.). I - - 2025
PLAN CHECKING FEE
Lender's Name o 0 - 2G255
PERMIT ISSUING FEE O.3,3 O`8 S
Lender's Address ,
1 certify that I have read this application and state that the above TOTAL FEE
information is correct. 1 agree to comply with all County ordinances
and S e laws regulating Electrical wiring, and hereby authorize
repre tatives of this County to enter upon the above mentioned
prop for inspection es. 3-3o
g
SEE REVERSE FOR EXPLANATORY LANGUAGE
S' ature of Per it ee Date