HomeMy Public PortalAbout5733AGNES AVE_Electrical (5) WORKERS'COMPENSATION DECLARATION CE-8 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that•.I have a pertificate o`consent to self insure,• 'CE-806G
or a certificate of Workers' Compensation'lnsurance,•or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
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 inspection $ — $ LOCALITY "`�;�- i z
1 & 2-Family,Sq.Ft.
department. Multi-family Sq.Ft. — NEAREST
CROSS ST. b!,i V t �
Date Applicant Residential Swimming Pools OWNER OR
FIM
NAME - L '
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec— Light Sw. MAIL L i--
COMPENSATION INSURANCE ADDRESS
This,section need not be com leted if the work involved by the First 20
( p Total No. Additional CITY Ey_ y- �--, Tel.No.' �f (?•-�
permit is for-one hundred dollars ($100)or less:)
I certifythat in the performance of the work'for which this permit PLAN CHECK
P p APPLICANT
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
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation Range_ HeaterD.W. _ APPLICANT
_
provisions of the Labor Code, you must forthwith comply with such Oven _ Dryer _ W.M. _ ADDRESS
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H.
CITY Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR
(commencing with Section 7000) of Division 3 of the Business and REG.NUMBER Class.
Professions Code,and my license is in full force and effect' DISTRICT NO. PR SED
Power Apparatus& Large Appliances d
Size& Type HP,KW,KVA,or KVAR
License Number Lic.ClassFINAL
Over
U
r 1 Incl.
Over 1 to 10 Incl. DATE //1
1 VALIDATION O
Contractor Date Over 10 to 50 Incl. FINAL V
❑ I am exempt under Sec. Over 50 to 100 Inc. BY ��
B.&P.C.for this reason Over 100 Z
Services, Swbd.,MCC &Panelboards
Date: 0- 200 Amp.Under 600 V
pol-
Signature 201 =•1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg.Maint.Elect. J,/
SINGLE FAMILY Temp.Power Pole & Appurtenances :f� �• _ qq�•. •y�
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ri41 r8
I hereby affirm that I am exempt from the Contractor's License Law +�
for the following reason (Section 7031.5, Business and Professions Additional Sign Branch Circuits 3307
Code): i ITEM
EI h7
❑ I,as owner of the property,will do the work and the structure Misc.Conduits & Conductors
( Other See Complete Fee Schedule) TOM 25.50
is not intended or offered for sale Section 7044, Business ( p
and Professions Code).
CHECK 25.50
CONSTRUCTION LENDING AGENCY r p�1�± nt
I hereby affirm that there is a construction lending agency for the CHANGE .011
performance of the•work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) 1 ""
Civ. C.).
PLAN CHECKING FEE - O � i 10/25/89
Lender's Name
PERMIT ISSUING FEE 6393 1 Al 8:54
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE
information is correct. I agree to comply with all County ordinances —
and State laws regulating Electrical wiring, and hereby authorize
representatives of County to enter upon the above-mentioned
proper or inspelbdo
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date