HomeMy Public PortalAbout5812AGNES AVE_Electrical (2) ERS COMPENSATION DECLARATION �EA�G 10i81 APPLICATION FOR ELECTRICAL PERMIT
i that t have a certificate of consent to self
nsui rtificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a opy thereof (Sec 3800 Lab C )
Policy o Company FOR APPLICANT TO FILL IN JOB Sr
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS__) < rl
❑ Certified copy is filed with the county building inspec 1 & 2 Family Sq Ft $ — $ LOCALITY
tion department Multi family Sq Ft — NEAREST Q �
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ST fI/l�
CROSS FI
Residential Swimming Pools d�i���
Date Applicant FIRM NAME I/
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec9_1_Light_Y�_Sw 'IL
COMPENSATION INSURANCE Total No First 20 ADDRESS C /
(This section need not be completed if the work involved by Additional CITY Tel N
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
so as to become subject to the Workers Compensation Laws lighting Fixtures First 20 ADDRESS /
Total No Additional
CITY el No
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT If after making this Certificate of APPLICANT
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 LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO PROCESSED EL
andProfessions Code and my license is in full force and effect Power Apparatus 8 Large Appliances //f� O
Size &Type HP KW KVA or KVAR 661 Vc+ U
License Number Lic Class Up to 1 Incl FINAL
Over 1 to 10 Incl DATE r
Contractor Date VALIDATION U
❑ Over 10 to 50 Incl
I am exempt under Sec Over 50 to 100 Inc FINA' ` (L
0
B&P C for this reason Over 100 Z_
Date Services Swbd MCC& Panelboards ® x
0 200 Amp Under 600 V
Signature _ 201 1000 Amp Under 600V
❑ Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V —4 310 7 3 A,
SINGLE FAMILY Temp Power Pole 8 Appurtenances # o o 9 o e 2
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit j) o 0 2 7 7 5 1
1 hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits i GO
eo 7 O 5 v t
Law for the following reason (Section 7031 5 Business andtS 5
Professions Code)
❑ I as owner of the property will do the work and the Misc Conduits 8 Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ,
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE
Lender s Name
PERMIT ISSUING FEE /
Lender s Address
I certify that I have read this application and state that the TOTAL FEE r S
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 mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date