HomeMy Public PortalAbout5226AGNES AVE_Electrical (9) WORKERS COMPENSATION DECLARATION 63
` CE APPLICATION FOVELECTRICAL ,PERMIT
CE 8 806G (2 80)
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES \/ _�� BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C) '
_ FOR APPLICANT TO FILL IN JOB r� r ��N��rs�
Policy No Company ADDRESS J Soa f
New Residential Bldgs &Pools EACH NO FEE
Certified copy is hereby furnished 1 &2 Family Sq Ft — $ LOCALITY :;Kir
Multi family Sq Ft — NEAREST
Certified copy is�filed with the county building inspection Residential Swimming Pools CROSS
department L ST �
r OWNER OR _
FIRM NAME ��
�,
Date Applicant Outlets Re r Light Sw r� A
-11 AIL
First 20 DDRESS ' -Jr—
_
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY I FTeI No
t COMPENSATION INSURANCE /
! PLAN CHECK d
(This section need not be completed if the work involved / PPLICANT O
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 / ADDRESS
Additional cc
Total No �� O
I certify that m the performance of the work for which this ✓
r , Fixed Appliances Not Over 1 HP l CITY Tel No �
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 W
0.
t t Oven Dryer_W M ADDRESS
Top FAU _W H Y Z
Date Applicant 1 CITY Tel No j
Hood Fan _Other_
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room+Air Cond_ LICENSE OR i
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 j P5pCE ED BY '
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVAR
deemed revoked ,e
I Up to 1 Incl r
� � I Over 1 to 10 Incl FINALDATE
LICENSED CONTRACTORS DECLARATION } Over 10 to 50 Incl "�� r�Z VALIDATION
( FINAL
I hereby affirm that I am licensed under provisions of Chapter , Over 50 to,100 Inc
9 (commencing with Section 7000) of Division 3�of the Busi Over 100 BY `
ness and Professions Code and my license is in full force and
effect Services
> 1 r 0 200 Amp Under 6001 V
License Number Lic Class
201 1000 Amp Under 600 V
Contractor (Date i Over 1000 Amp or Over 600 V a
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances 2 2 0 7 7 A
l 1
I hereby affirm that I am exempt from the Contractors r Sign with One Branch Circuit
Additional Sign Branch Circuits ) # oto o o ° 2
Licen Law for the following reason (Section 7031 5 Busi i i ,
.e. nd Professions Code) ( i
Mlsc Conduits&Conductors_ ,2,° ° 11 5 0 ,
I as owner of the property will do the work and the Other (See Complete Fee Schedule)— o o to 1 1 5 0
structure is not intended or offered for sale (Section _
7044 Business and Professions Code) '
CONSTRUCTION LENDING AGLNCY ) 1 1 2 4—8
I hereby affirm that there is a construction lending agency
for the performance of the work to which this permit is PERMIT FEE ) (Sub Total) 1
issued (Sec 3097 Civ C) / )
Lenders Name PLAN CHECKING FEE (One Fourth Permit Fee) \
i
Lender s Address I PERMIT ISSUING FEE !
I certify that I have read this application and state that the TOTAL FEE 4
above information is correct I agree to comply with all County
ordinances and t e laws regulating Electrical wiring and
hereby aut r r resentatives of this County to enter upon
the above en i ne operty for inspection purposes i
i � ) SEE REVERSE FOR EXPLANATORY LANGUAGE
,
r
Signature o r Date Jr ` t