HomeMy Public PortalAbout5226AGNES AVE_Electrical (4) vyeRKER S COMPENSATION DECLARATION 20 DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT
76A663
I hereby affirm that I have a certificate of consent to self Insure 76A663
or a certificate of Worker s Compensation Insurance or a certified COUNTY OF LOS ANGELES - DEPT OF PUBLIC WORKS BUILDING AND SAF;TY DIV
copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN JOB
ADDRESS rJ 4
Certified copy Is hereby furnished New Residential Bldgs &Pools NO EACH FEE
❑ _ $ $ LOCALITY
Certified copy Is filed with the county building inspection 1 &2 Family Sq Ft
department Multifamily Sq Ft NEAREST
department
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAG PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec -Light Sw OWNEROR
COMPENSATION INSURANCE FIRM NAMEt
First 20 +
(This section need not be completed if the work Involved?by the Total No Additional MAIL ESS
permit is for one hundred dollars($100)or less)
I certify that In the performance of the work for which this permit CITYTei No �..
Is Issued I shall not employ any person In any manner so as to PLAN
become subject to the Workers Compensation Laws Lighting Fixtures First 20 APPLICANT
K
Total No Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If after making this Certificate of CITY Tel No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
provisions of the Labor Code you must forthwith comply with such PERMIT
provisions or this permit shall be deemed revoked Power Apparatus&Large Appliances APPLICANT
LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS
I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl
(commencing with Section 7000) of Division 3 of the Business and CITY Tel No
Professions Code and my license Is In full force and effect Over 10 to 50 Incl
Over 50 to 100 Incl LICENSE OR }
REG NUMBER Class a
Over 100 DISTRICT NO SSED BY 0
License Number Llc Class 0
Services Swbd MCC&Panelboards cc
Contractor Date 0 399 Amp Under 600 V FINAL DATE _ 0
El 400 1000 Amp Under 600V
I am exempt under SecVALIDATION
Over 1000 Amp or Over 600 V FINAL 1 W
B&P C for this reasonBRANCH CIRCUIT FEES BY f.(J\ U)
Date 15A or 20A 120V Lighting or Recept Z
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
F-141 Or More Branch Circuits M
Exemption for Reg Mamt Elect 15A 20A 208V To 277V Lighting Br Circuits
SINGLE FAMILY + Vi - - Temp Power Pole&Appurtenances
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractors License Law - � 7/th'�
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits .3303 70u 10
Code)
1 ITEMSd
&C
t
d
Conuis Conductors I as owner of the property will do the work and the structure Mlsc iy Af
s not Intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) TOTAL 70 m 1113
and Professions Code)
_ CHECK - 70.10
CONSTRUCTION LENDING AGENCY I �{y
I hereby affirm that there Is a construction lending agency for the &011 8�T[f3PR',Ji
performance of the work for which this permit Is Issued (Sec 3097 PERMIT FEE (Sub Total) _
CIV C)
PLAN CHECKING FEE
Lender s Name L
PERMIT ISSUING FEE a
Lender s Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the 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 u on the above mentioned property
f r ection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGN URE OF PERMITT DATE