HomeMy Public PortalAbout5733AGNES AVE_Electrical (3) WORKERS' COMPENSATION DECLARATION 2o-ooieDPW 3ia7 APPLICATION FOR ELECTRICAL PERMIT
1 hereby affirm that I have a certificate of consent to self CE 8 oG
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
❑Certified copy is filed with the county building inspec- 1 & 2-Family, Sq. Ft. $ _ $ LOCALITY
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tion department. Multi-family Sq. Ft NEAREST� CROSS ST. � �� "� " �-�/ 06&�
Date Applicant Residential Swimming Pools OWNER OR J/� y 's
FIRM NAME � �{f'i
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE First 20 ADDRESS
(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 Lighting Fixtures First 20 ADDRESS
so as to become subject to the Workers'Compensation Laws.
Additional
Total No. CITY Tel. No.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate 'of' Fixed Appliances Not Over 1 HP PERMIT
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. Hood — Fan —Other— CITY Tel. No.
LICENSED CONTRACTORS DECLARATION Disp. — Room Air Cond. — LICENSE OR Class.
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO. PROCESSED BY >_
and Professions Code,and my license is in full force and effect. �� O
Size &Type HP, KW, KVA, or KVAR
License Number Lic. ClassU
Up to 1 Incl. FINAL
Contractor Date Over 1 to 10 Incl. DATE - /9- VALIDATION Cc
Over 10 to 50 Incl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY U
LU
B.&P.C. for this reason Over 100 Q_
®
Date: Services, Swbd., MCC& Paneiboards Z
0- 200 Amp. Under 600 V Z
Signature 201 - 1000 Amp. Under 600 V
aExemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY
HOME OWNER-BUILDER DECLARATION Temp. Power Pole &Appurtenances _
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit
Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Profes 'o`ns Code):
Misc. Conduits& Conductors
I, as owner of the property, will do the work and the
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)_
Business and Professions Code).
CONSTRUCTION LENDING AGENCY ""HEU a:-
I hereby affirm that there is a construction lending agency for i. y - -,--
the performance of the work for which this permit is issued PERMI E � � (Sub-T al) = f" 3-
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE q
Lender's Name i?i131?-i ii f, i € ;iL 1
PERMIT ISSUING FEE ` 9O
Lender's Address =9F? j Air< <;
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 representatives of this County to enter upon
the above-mention d roperty for in pectin purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Sig t re
es Per ee Date
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