Loading...
HomeMy Public PortalAbout5733AGNES AVE_Electrical (2) WORMERS' CI have* AJION DEG';-of consent 76A613 DPW 3/87 APPLICATION FOR ELECTRICAL PERMIT O I hereby affirm that I have a certificate of consent to self ce 8006G insure, or a certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS or a certified copy thereof (Sec. 3800, Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ❑Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS `r!�3 3 0-- LACertified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. 4,153 $ — $ LOCALITY tion department. Multi-family Sq. Ft. — NEAREST Date Applicant Residential Swimming Pools CROSS ST. OWNER OR `�/.� FIRM NAME L�.Zk� CERTIFICATE OF EXEMPTION FRVM RKERS' Outlets: Rec Light Sw._ MAIL COMPENSATION INSURANCE First 20 ADDRESS Q/Y)'L e _ (This section need not be completed if the work involved by Total No. Additional CITY Tel. No. the permit is for one hundred dollars ($100)or less.) PLAN CHECK I certify that in the performance of the work for which this APPLICANT permit 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 ADDRESS Additional Total No. CITY Tel. No. Date Applicant Fixed Appliances Not Over 1 HP PERMIT 19 9 NOTICE TO APPLICANT: If, after making this Certificate of APPLICATION 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._ ADDRESS with comply with such provisions or this permit shall be Top — FAU —W.H. — deemed revoked. CITY Tel. No. 4 LICENSED CONTRACTORS DECLARATION Hood — Fan —Other— 4c3 2_c Disp. — Room Air Cond. _ LICENSE OR c ` @_ S-34_ 3 Class. �d (commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT O. PROCE EDB >- and Professions Code,and my license is in full force and effect. Size & Type HP, KW, KVA, or KVAR - Q License Number(0 V-3-V Lic. Class �d Up to 1 Incl. FINAL U Contractor +v Date �� Over 1 to 10 Incl. DATE f VALIDATION cc Over 10 to 50 Incl. FINAL ❑ I am exe pt under Sec. Over 50 to 100 Inc. BY W B.&P.C. for this reason Over 100 t1 Services, Swbd., MCC& Ponelboards Date: 0-200 Amp. Under 600 V Z Signature 201 - 1000 Amp. Under 600 V ❑ Over 1000 Amp. or Over 600 V Exemption for Reg. Maint. Elect. SINGLE FAMILY Temp. Power Pole &Appurtenances HOME OWNER-BUILDER DECLARATION � I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits _-T Professions Code): -- .655 1 l; 13 ❑ I, as owner of the property, will do the work and the Misc. Conduits &Conductors s "i w)C = structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_ ® i�I')"AL 139 - 65 Business and Professions Code). CONSTRUCTION LENDING AGENCY CHECK 13 65 I hereby affirm that there is a construction lending agency for CHANGE ,iii 1 the performance of the work for which this permit is issued PERMIT FEE (Sub-Total) (Sec. 3097, Civ. C.). >91i Lender's Name PLAN CHECKING FEE 01000-000_ 1 1/.L,;:i ii t PERMIT ISSUING FEE ? ,?'?7 1 AM U;.3 Lender's Address y I certify that I have read this application and state that the I TOTAL FEE e above information is correct. I agree to comply with all County ordinances and State laws regulating.Electrical wiring, and hereby outhor.ize representatives of this County to enter upon the above-mentioned property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE Signature of Permute Date�� ©s