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HomeMy Public PortalAbout5749AGNES AVE_Electrical (2) WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) 76A663 _ APPLICATION FOR ELECTRICALPERMIT I hereby affirm that I have a certificate of consent to self insure, ". or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES : F":T >OF'PUBLIC-WORKS BUILDING AND"SAFETY DIV. copyethereof(Sec.3800 Lab. C.) Policy No. Company FOR APPLICANT TO FILL IN JOB ADDRESS S 7 %`7l Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE ❑ LOCALITY _ 1&2-Family,Sq.Ft. ' Certified copy is filed with the county building inspection —_ $ � NEAREST I department. Multi-family Sq.Ft. CROSS ST. Residential Swimming Pools ASSESSOR „t Date Applicant + MAP BOOK PAGE - •:'PARCE4�` CERTIFICATE OF EXEMPTION FROM WORKERS' OWNER OR " Outlets: Rec.-�Light Sw. h COMPENSATION INSURANCE First 20 % FIRM NAME`i (This section need not be completed if the work involved by the MAIL: '.' permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS S 7 y I certify that in the performance of the work for which this permit CITY is issued, I shall not employ any person in any manner so as to PLAN > become subject to the Workers' Compensation Laws. Lighting Fixtures First 20 APPLICANT PPLIC NT 1 P g APPLICANTxECK Z, :, T al No. Additional sf i 'ry Or�.• ADDRESS Date /�'�' 9� Applicant I ENTIAL APPLIANCES NOT OVER 3 HP. NOTICE TO APPLICANT: If, after maki his Certificate of CITY 1, /Te I.No. Exemption,you should become subject to the Workers' Compensation OTHER APPLIANCES NOT OVER 3 HP. .✓ =��F":.. . 7J' :. provisions of the Labor Code, you must forthwith comply with such PERMIT provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT / '^9�•� t Ant Size&Type HP,KW,KVA,or KVAR LICENSED CONTRACTORS DECLARATION YP ADDRESS I hereby affirm that I am licensed under provisions of Chapter 9 Over 3 to 10 Incl. (commencing with Section 7000) of Division 3 of the Business and CITY �'g . TeLN0 �rj- ��•'/ Professions Code, and my license is in full force and effect. Over 10 to 50 Incl. Over 50 to 100 IncClassREG.N ER `/76 . ilY C f Over 100 DISTRICT NO. PRO E �flY:�, a' License Number `� /�r�' Lic.Class 7/ Services,Swbd.,MCC&Panelboards I ©� t Contractor �`° Date 0-399 Amp.Under 600 V FINAL DATE k� O F- 400-1000 Amp. Under 600 V j`+ " (� ❑ VALIDATION I am exempt under Sec. Over 1000 Amp.or Over 600 V FINAL B.&P.C.for this reason BRANCH CIRCUIT FEES ev U).•. Date: 15A,or 20A, 120V,Lighting or Recept. -; 1 To 10 Branch Circuits Signature ` 1 :%s ✓ 4 11 To 40 Branch Circuits F141 Or More Branch Circuits .J Exemption for Reg. Maint.Elect. 15A,20A,208V To 277V Lighting Br.Circuits SINGLE FAMILY Temp.Power Pole&Appurtenances HOME OWNER-BUILDER DECLARATION i=_ I hereby affirm that I am exempt from the Contractor's License Law Sign with One Branch Circuit (; for the following reason Section 7031.5, Business and Professions Additional Sin Branch Circuits ( 9 Code): ❑ Misc.Conduits&Conductors r • I,as owner of the property,will do the work and the structure is not intended or offered for sale (Section 7044, Business Other(See Complete Fee•Schedule) t, �•moi �2, 17 41 and Professions Code). CONSTRUCTION LENDING AGENCY , �- f- ITEMS I hereby affirm that there is a construction lending agency for the -� 67 performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) ' ti (1 � ' Civ. C.) ` -f; PLAN CHECKING FEE s 7 Xrydv TU "A Lender's NameI';r{ PERMIT ISSUING FEE 4 '75 Lender's Address , y^} S I certify that I have read this application and under penalty of purjury state TOTAL FEES that the above information is correct. I agree to comply with all County ordinances and State laws regulating Electrical wiring,and hereby authorize � F representatives of this County to enter upon the above-mentioned property for inspection purposes. Y SEE REVERSE FOR EXPLANATORY LANGUAGE /2�?—9 7 %. SIGNAT OF PERMITTEE DATE