HomeMy Public PortalAbout5733AGNES AVE_Electrical (4) WORKERS COMPENSATION DECLARATION 76A663 r 5
'W". I CE806�(280)— APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELESti- /� BUILDING AND'SAFETY
insure or a certificate of W rkers Compensation nsurance or -'—' (\-�--'-
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a cpe-r�tJt/fi copy tlhereof(S 3800 ab C) f�1t
Policy o�0-�Il o pany wS FOR APPLICANT TO FILL IN JOB
ADDRESS
New Residential Bldgs &Pools EACH NO FEE
Certified copy is hereby furnished 1 &2 Family Sq Ft $ ' — $ LOCALITY
Multi family Sq Ft NEAREST
Certified copy is filed with the county building inspection CROSS ST
department Residential Swimming Pools OWNEROR
�f FIRM NAME
Date Applicant Outlets Rec L ht—
S V ADAIL
DRESS
t First 20 y
CERTIFICATE OF EXEMPTION FROM WORKERS
Total No Additional CITY Tel No }
COMPENSATION INSURANCE PLAN CHECK
APPLICANT ''r O
(This section need not be completed if the work involvedLighting Fixtures Fust 20 U
i
by the permit is for one hundred dollars ($100) or less) ADDRESS
AdditionalTotal No 153, O
1 certify that` in the performance of'the work for which this Fixed Appliances Not Over 1 HP CITY I No Il'—
permit is issued I shall not employ any person in any manner PERMIT A w
so as to become subject to the Workers Compensation Laws Range_ Heater_DW i APPLICANT Imo' a
Oven _ Dryer_W M ADDRESSIr &A04V
Date Applicant ' Top _ F WH _i _ Z
Hood _Other_ CITY Tel No 361
NOTICE TO APPLICANT If after making this Certificate of Disp41 Room Air Cond_ LICENSE OR
Lxemption you should become subject to the Workers % REG NUMBER Class
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances i DISTRICT N PR E BY
with comply with such provisions or this permit shall be 5 xJ
W
deemed revoked Size&Type HP KKVA or KVAR (f
Up to 1 Incl
FINAL
Over 1 to 10 Incl DATE
LICENSED CONTRACTORS DECLARATION / VALI DATI
Over 10 to 50 Incl /
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc BY AL
9 (commencing with Section 7000) of Division 3 of the Busi Over 100 rv�
ness and Professions Code and my license is in full force and
effect Services
License Nu e —3 Lic Class 0 200 Amp Under 600 VIV
201 1000 Amp Under 600 V
Contractor to Over 1000 Amp or Over 600 Vi- ' ;22263A
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
#�0 0 0 '0 0 2
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 2 010 30 7 Q
ness and Professions Code) a
Misc Conduits&Conductors 'a 0 0 30 7 o v
❑ I 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 121 1 —8 1
7044 Business and Professions Code) 1
CONSTRUCTION LENDING AGENCY
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)
issued (Sec 3097 Civ C)
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee)
Lender s Address J i
PERMIT ISSUING FEE
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 r
ordinances and State laws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
theabove boned property for inspection purpos SEE REVERSE FOR EXPLANATORY LANGUAGE
ignature of Permittee Efate