HomeMy Public PortalAbout5226AGNES AVE_Electrical (5) WORKERS'COMPENSATION DECLARATION C -663 10/81Ah APPLICATION FOR ELECTRICAL PERMIT
I tteret,y affirm that I have a certificate of consent to self insure, CE-806G
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.)
Policy No. Company. FOR APPLICANT TO FILL IN 'JOB /�^
❑ EACH NO. FEE ADDRESS 0 p(
Certified copy is hereby furnished. New Residential Bldgs.& Po�ol �
❑ 1 & 2-Family,Sq.Ft.'s $ = $ LOCALITY ,
Certified copy is filed with the county building inspection
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR '/
.FIRM NAME V,
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light �L Sw. MAIL
COMPENSATION INSURANCE GSD '� ADDRESS
This section need not be completed if the work involved b the First 20
( p y Total No. Additional CITY Tel.No
permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this permit m_elAPPLICANT
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 �' B� ADDRESS
Total No. Additional CITY Tel No.
Date" Applicant Fixed Appliances Not Over 1 HP
NOTICE TO, APPLICANT: If, after,making this Certificate of PERMIT
Exemption,you should become subject to the Workers',Compensation - Range_ Heater_ D.W. APPLICANT
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. CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby,affirm that I am licensed under provisions of Chapter 9LICENSE OR
Disp. Room Air Cond. REG.NUMBER Class. '
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. Power Apparatus& Large Appliances DISTRICT NO. p t ESSED BY
Size& Type HP, KW,KVA,or KVAR �Q
License Number Lic.Class Up to 1 Incl. FINAL
Over 1,to 10 Incl. DATE VALIDATION Q
Contractor' Date Over 10 to 50 Incl. FINAL 1� l U
❑ Lam exempt under Sec.' Over 50 to 100 Inc. BY OW
BAP.C.for this reason Over 100 Z
Services, d. MCC PaPaIrsDate: 0/200 Amp USignature 201 - 1000 Amp
. Wn
aOver 1000 Amp. or Over 600 V n
Exemption for Reg.Maint.Elect. __,_
SINGLE FAMILY Temp. Power Pole& Appurtenances .r3)i�. 1 _=`.•'
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law Additional Sin Branch Circuits
for the following reason(Section 7031.5, Business and Professions g -ITEMS
Code):
TOTAL AL x..05 c 6
Misc.Conduits & Conductors _
L 1,as owner of the property,will do the work and the structure �; U_
is not intended or offered for sale (Section 7044, Business _ Other (See,Complete Fee Schedule) '• tL�•e. . '==O'-r'
and Professions Code).
MME '
=IJILi
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(Sec.3097, PERMIT FEE (Sub-Total) } G:`95
Civ. C.).
PLAN CHECKING FEE -�- AN 92b
Lender's Name
PERMIT ISSUING FEE o
Lender's Address
I certify that I have read this application and state that the,above TOTAL FEE
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 above-mentioned
property for inspection pur ses.
X
S SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of P mittee 'o h �a