HomeMy Public PortalAbout5729AGNES AVE_Electrical (2) WORKERS COMPENSATION DECLARATION CE 863 10/e1 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE 8066
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab`O)
Policy No Company' 11),OA-1-G FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished 4,vc New Residential Bldgs & Pools EACH NO FEE ADDRESS
❑ Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ — $ LOCALITY
tion department Multi family Sq FT NEAREST
` Residential Swimming PoolsCROSS ST
Date Applicant OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec b ht�Sw ' MAIL
COMPENSATION INSURANCE ADDRESS
First 20
(This section need not be completed if the work involved by Total No p�- Additional CITY Tel No
the permit is for one hundred dollars ($100)or less )
PLA
I certify that in the performance of the work for which this PLCHECK
ICANT
permit is issued I shall not employ any person in any manner
so as to becom*LICANT
to the Work s Lighting Fixtures First 20 ADDRESS
� Total No T Additional
CITY Tel No �
Date pplicant �-^'- Fixed Appliances Not Over 1 HP PERMIT
NOTICE40 A If after making this Certificate of APPLICANT
Exemption you should become subject to the Workers Range_ Heater_D W
Compensation provisions of the Labor Code you must forth Oven _ Dryer — W M — ADDRESSell
with comply with such provisions or This permit shall be Top _ FAU —W H
deemed revoked Hood Fan _Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION - LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Class G
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PZ-a&e-'er
D BY
and Professions Code and my license is in full force and effect Power Apparatus & Large Appliances 0.
Size & Type HP KW KVA or KVAR L7O
License N� i Lic Class ���� Up to 1 Incl FINAL V
Over 1 to 10 Incl JB
ATE 'f cc
VALIDATIONverContracto ate O 10 to 50 Incl NALI am exempt under Sec Over 50 to 100 Inc Y d
B&P C for this reason Over 100
Dare Services S A MCC& Panelboards -
0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V
❑ Exemption for Reg Maint Elect , Over 1000 Amp or Over 600 V g 6 3 1 2A
SINGLE FAMILY Temp Power Pole& Appurtenances # o o o o o 2
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s License 20o ,3525
Law for the following reason (Section 7031 5 Business and Additional Sign Branch Circuits /
Professions Code) 0 0 0 3 F, 2 5 c=a
❑ I as owner of the property will do the work and the Misc Conduits& Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ( 025-83
7044 Business and Professions Code)
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 PERMIT FEE (Sub Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE 7 �
Lender s Address
I certify that I have read this application and state that the TOTAL FEE
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring and
hereby authorize re resentatives of this County to enter upon
t e pr pert for inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Pe ittee 16ate _