HomeMy Public PortalAbout5732AGNES AVE_Electrical '-A WORIQ tS COMPENSATION DECLARATION 63
' 0 CECE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
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I hereby affirm that I have a certificate of consent'to self COUNTY OF LOS ANGELES C. � BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or
a certified copy thereof(Sec 3800 Lab C)
FOR APPLICANT TO FILL JOB
Policy No Company EACHNOADDRESS NFEE DRESS `2
New Residential Bldgs &Pools �"
❑ Certified copy is hereby furnished 1 &2 Family Sq Ft $ — $ LOCALITY Qjy1 Q Cf�
— NEAREST
Certified copy is filed with the county building inspection Multi family Sq Ft CROSS ST Q). /J)
department Residential Swimming Pools OWNER OR
7 FIRM NAME a
Date Applicant Outlets Reo2�Light// Sw 16MAIL ry 1
First 20 ADDRESS / A Q /
CERTIFICATE OF EXEMPTION FROM WORKERS Total No6�0 Additional ' CITY CG Tel No2f5p,0Sv
COMPENSATION INSURANCE d
PLAN CHE 0
APPLICANT �j(�Al? V
(This section need not be completed if the work involved ('e /� P76-1
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First io ADDRESS 2
Total No �7 Additional 0
I certify that in the performance of the work for which this Fixed Appliancest Over 1 HP CITY + Tel No U
permit is issued I shall not employ any person in any manner PERMIT W
so as to become subject to the Workers Compensation Laws Range_ Heater_D W APPLICANT OklAjeAd
Oven _ Dryer L W M ADDRESS Z
Date Applicant
Top _ FAU _LW H
Hood — Fan _Other_ CITY Tel No
NOTICE TO APPLICANT if after making this Certificate of Disp _ Room Air Cond
Exemption you should obecome subject to the Workers REG NUMBER Class
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PR ED BY
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVAR
deemed revoked /o
Up to 1 Incl
_ FINAL
Over 1 to 10 Incl DATE / —� VALIDA ION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl / f
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
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
0 200 Amp Under 600 V
License Number Lic Class 201 1000 Amp Under 600 V
Contractor Date Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code)
Misc Conduits&Conductors
[ as owner of the property will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044 Business and Professions Code) 2'2 5 5.2 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency �# o a 0 o`o 2
for the performance of the work for which this permit is PERMIT FEE (Sub Total) ,
issued Sec 3097 Civ C)
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) f of - 3280 3 2 8 0
o
Lender s Address PERMIT ISSUING FEE r ° ° ° 3 2 8 0 5
1009'-80
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 representati es of is County to enter upon
the above menti ed p pert for pection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE '
Signature of Permittee Date