HomeMy Public PortalAbout5732AGNES AVE_Electrical (2) A
WO RS COMPENSATION DECLARATION 63
CE 8
� CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
I herebf affirm that I have a certifitate 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) L
FOR APPLICANT TO FILL IN JOB
Policy No Company ADDRESS v
New Residential Bldgs &Pools EACH NO FEE
Certified copy is hereby furnished 1 &2 Family Scl Ft $ — $ LOCALITY 7490
❑ Multi family Scl Ft — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department Residential Swimming Pools OWNER ORr
FIRM NAME 'I' f
Date Applicant Outlets Re2f Light Sw -S CFO �� ADDRESS AIL
�-/ First 20
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITY el No
COMPENSATION INSURANCE - >_S?' PLAN CH - LL
t 117 r� APPLICANT 0 0
(This section need not be completed if the work involved Lighting Fixtures First 20 ADDRESS 0
by the permit is for one hundred dollars ($100) or less)
Total No �� Additional cc
I certify that in the performance of the work for which thisFixed Appliances Not Over 1 HP CITY Tel No 0
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
ADDRESS
Oven _ Dryer L W M G'
Z
Date Applicant Top _ FAU L W H _
Hood — Fan _Other_ CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE O
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 PROCE ED BY
1-17
with comply with such provisions or this permit shall be Size&Type HP KW KVA or KVAR � �+
deemed revoked lJ / (✓
Up to 1 Incl
FINAL
Over 1 to 10 Incl
LICENSED CONTRACTORS DECLARATION DATE / ^)� VALIDATI N
Over 10 to 50 Incl �►(®
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 -�Cy�-•—•�
ness and Professions Code and my license is in full force and
effect Services 1,41e lea ,Q , 49 v
License Number Lic Class 0 200 Amp Under 650, V
201 1000 Amp Under 600 V
Contractor Date Over)000 Amp or Over 600 V
r
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor s Sign with One Branch Circuit
License Law for the following ieason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code) q
Misc Conduits&Conductors
.l(I I as owner of the property will do the work and the Other (See Complete Fee Schedule)— 2 5 8 a
structure is not intended or offered for sale (Section
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY # o o 0 o o 2
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub Total) 2 - 5380
issued (Sec 3097 Civ C) -
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee) o 0 o 53806
Lender s Address PERMIT ISSUING FEE 0 di 0 r 8 0
a
I certify that I have read this application and state that the TOTAL FEE �—
above information is correct I agree to coin y with all County
ordinances and State laws regulating E tricaI wiring and i
hereby authorize represe tatives o this ounty to enter upon 1
the above mentio ed pr erty o ins p ion purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date