HomeMy Public PortalAbout5749AGNES AVE_Electrical (3) WORKER'S COMPENSATION DECLARATION 20-0019 DPW(12-91) APPLICATION FOR ELECTRICAL PERMIT LI
I hereby affirm that I have a certificate of consent to self insure, 76A663
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec. 3800 Lab. C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB —7
ADDRESS /
Certified copy is hereby furnished. New Residential Bldgs.&Pools NO. EACH FEE
El
$ $ LOCALITY �s�' �—
Certified copy is filed with the county building inspection 1&2-Family,Sq.Ft. NEAREST
department. Multi-family Sq,Ft. CROSS ST.
Date Applicant Residential Swimming Pools ASSESSOR
MAP BOOK PAGE GZ PARCEL D
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec. Light�Sw. OWNER OR
COMPENSATION INSURANCE �D G FIRM NAME j
First 20 O
(This section need not be completed if the work involved by the MAIL
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permit is for one hundred dollars($100)or less.) Total No.� s Additional - �r
I certify that in the performance of the work for which this permit CITY 1 r L T�� L 24 70
Tel.No.
is issued, I shall not employ any person in any manner so as to PLAN
become subject to the Workers' Compensa i n L ws. Lighting Fixtures First 20 APPLICANT
Total No. Additional PV
4ADDRESS
Date `Z Applicant �� / RESIDENTIAL APPLIANCES NOT OVER 3 HP.
NOTICE TO APPLI ANT: If, after maki g this C rtificate of CITY Tel.No.
Exemption,you should become subject to th Workers' Compens Ion OTHER APPLIANCES NOT OVER 3 HP.
provisions of the Labor Code, you must forthwith comply with such PERMIT
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provisions or this permit shall be deemed revoked. Power Apparatus&Large Appliances APPLICANT G
LICENSED CONTRACTORS DECLARATION Size&Type HP,KW,KVA,or KVAR ADDRESS I
I hereby affirm that I am•licensed under provisions of Chapter 9 Over 3to 10 Incl.
(commencing with Section 7000) of Division 3 of the Business and CITY �LL� � Tel.No. Z
Professions Code,and my license is in full force and effect. Over 10 to 50 Incl. &i/� (O
Over 50 t0 100 Incl. LICENS OR / Class. � d
REG.NUMBER
License Number �/+Y-'Y Over 100 DISTRICT NO. P ESSED BY 0
�Lic.Class�� V
Services,Swbd.,MCC&Panelboards ���Qoe.� cc
Contractor - Date '2 0-399 Amp.Under 600 V FINAL 0
DATE
❑ I am . 400-1000 Amp.Under 600 V
exempt under Sec � ~
Over 1000 Amp.or Over 600 V FINAL VALIDATION W
B.&P.C.for this reasonBRANCH CIRCUIT FEES BY U)
Date: 15A,or 20A, 120V,Lighting or Recept.
1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
❑ 41 Or More Branch Circuits
Exemption for Reg. Maint.Elect. 15A.20A,208V To 277V Lighting Br.Circuits
SINGLE FAMILY Temp.Power Pole&AppurtenancesUY =L of
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit i _1 }1-:i
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 .............. ?:r_Ts 4
Code): II-�L 6 40
EJMisc.Conduits&Conductors 1-;-I'_CK 12.41 I
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) C'H pS )jl
and Professions Code). ?`a3' a -'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the 001100-00101111 • f :f 4
performance of the work for which this permit is issued (Sec. 3097, PERMIT FEE (Sub-Total) — �Sf•e r, c;:
Civ.c.) -
02
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE (�
Lender's Address
I certify that I have read this application and under penalty of purjury state TOTAL FEE
that the above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring,and hereby authorize
represe tives of this ounty to nter pon the above-mentioned property
for in t' n p pos SEE REVERSE FOR EXPLANATORY LANGUAGE
, 2—
I N U OF ER ITTEE DATE -