HomeMy Public PortalAbout5226AGNES AVE_Electrical (10) �yy frm that
I have
a ceSeT10N DECLARATION 76A606 10/e1 ,APPLICATION FOR ELECTRICAL PERMIT � {�
+t her�Oy affirm that I have a certificate of consent to self insure CE Bo6G LJ
or a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C)
Poli y No Company FOR APPLICANT TO FILL IN JOB
urnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
Certified copy is hereby f
1� � LOCALITY .�pp
Certified copy is filed with the county,building inspection 1 & 2 Family Sq Ft $ — $ G�
department Multi family Sq Ft — NEAREST
Date Applicant Residential wimmmg Pools
OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERSo; ` MAIL
Outlets Re Light Sw —
ti COMPENSATION INSURANCE ADDRESS
(This section need not be completed if the work involved by the First 20 CITY Tel No ZS7�yz
permit Is for one hundred dollars ($100)or less) Total No Additional -622
1 certifythat in the performance of the work for which this permit _ PLAN CHECK
s
p p { APPLICANT
is issued I shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS01 ;
Additional
/ Total No CITY Tel No
Date / ` Apphcan
Fixed Appliances Not Over 1 HP PERMIT
NOTICE A LICANT If after making s Cerhficate i
Exemption you should become subject to the W6rkers Compensation Range_ Heater r DW _ APPLICANT
provisions of,the Labor Code you must forthwith comply with such Oven _ Dryer _ W M _ a ADDRESS
provisions or this permit shall be deemed revoked Top — FAU _ W H
CITY Tel No
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under,provisions of Chapter 9 Disp — Room Air Cond LICENSE OR
(commencing with Section 7000) of Division 3 of the'Business and REG NUMBER Class
Professions Code and my license is in full force and effect Power Apparatus& Large Appliances DISTRICTOO�LPRC ED BY
+ Size& Type HP KW KVA or KVAR �Q� G
License Number Lic Class Up to 1 Incl FINAL V
Over 1 to 10 Incl DATE 1`_`/l7 ^` 3 VALIDATION 0
Contractor Date Over 10 to 50 Incl [ �j
❑
FINAL
I am exempt under Sec Over 50 to 100 Inc BY W
B&PC for this reason — _ Over 100. nelCl)
u5.—,v,ces Swbd MCC& Paboard Z'
Date 0 200 Amp Under 600 V q
Signature 201 1000 Amp Under 60 v # 1 4 1 6 2
0 0 0 0 0
❑ v Over 1000 Amp or O 600 V
Exemption for Reg Mamt Elect
r SINGLE FAMILY _,,,Temp Power Pole& Appurtenances o o e=
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that loam exempt from the Contractors License Law t additional Sign Branch Circuits
the following reason(Section 7031 5 Business and Professions
r Code c zj rr X 2 2 9E$a
I Misc Conduits & Conductors
I as owner of the property will do the work and the structure r
is not intended or offered for sale (Section 7044 Business �J Other (See Complete Fee Schedule) ® ,
and Professions Code) > M s
1 �
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)
Civ C)� l
PLAN CHECKING FEE
Lenders Name
n < I PERMIT ISSUING FEE
Lenders 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 purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE iy T
ignature 7rmittee UDate
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