HomeMy Public PortalAbout5817AGNES AVE_Electrical (5) WORKER S COMPENSATION DECLARATION DPW(12 91) APPLICATION FOR ELECTRICAL PERMIT
76A663
I hereby affirm that I fiave 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 11,j� - Company 4 /r�/ FOR APPLICANT TO FILL IN JOB
ADDRESS
Certified copy is hereby furnished New Residential Bldgs &Pools NO EACH FEE
— $ $ LOCALITY 7-6
Certified co is filed with e county h tht building ms 1&2 Family Sq Ft
copy yudg p ection NEAREST
department
Multifamily Sq Ft CROSS ST
Date Appllcanr�k �`1,��, Residential Swimming Pools MAPEBOOK
PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM WORKERS Outlets Rec -L-Light Sw OWNER OR t
COMPENSATION INSURANCE d�7 /O FIRM NAME g,
0 jb (N 15,
(This section need not be completed MAIL
the work Involved by the First 2Total No Additional ADDRESS
permit Is for one hundred dollars($1000)or less)
I certify that in the performance of the work for which this permit CITY �' Tel No
is Issued I shall not employ any person in any manner so as to
become subject to the Workers Compensation Laws Lighten Fixtures First 20 PLAN CHECK
J p 9 APPLICANT
Total No Additional
ADDRESS
Date Applicant RESIDENTIAL APPLIANCES NOT OVER 3 HP
NOTICE TO APPLICANT If after making this Certificate of CITY Tel No
Exemption you should become subject to the Workers Compensation OTHER APPLIANCES NOT OVER 3 HP
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
LICENSED CONTRACTORS DECLARATION Size&Type HP KW KVA or KVAR ADDRESS 9106&
1 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 Tel No
Professions Code and my license is in full force and effect Over 10 to 50 InclOR }
Over 50 to 100 Incl LICENSE REG NUMDISTRICT
Class d
License Number � � LIC Class � Over 100 DISTRICT NO ESSED BY O
Services Swbd MCC&Panelboards cc
-� 0 399 Amp Under 600 V FINAL 0
Contractor Date DATE F-
❑ I am exempt under Sec 400 1000 Amp Under 600V I- VALIDATION w
Over 1000 Amp or Over 600 V FINAL d
B&P C for this reason BRANCH CIRCUIT FEES BY
Date 15A or 20 120V Lighting or Recept ' Z
A 1 To 10 Branch Circuits
Signature 11 To 40 Branch Circuits
El Exemption
Or More Branch Clrcwts
Exemption for Reg Maint Elect 15A 20A 208V To 277V Lighting Br Circuits 2
SINGLE FAMILY Temp Power Pole&Appurtenances A/�
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit
ACCToT
I hereby affirm that I am exempt from the Contractors License Law 60ti('t� ti''�
for the following reason (Section 7031 5 Business and Professions Additional Sign Branch Circuits 33Q3303 .40
Code) 1 ITEMS
❑ I as owner of the property will do the work and the structure Misc Conduits&Conductors �4I s�
is not intended or offered for sale (Section 7044 Bu„iness Other(See Complete Fee Schedule) TOTAL 450_40
and Professions Code) , CHECK 60 4 0
CONSTRUCTION LENDING AGENCY CANGE a nVQ
1 hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued (Sec 3097 PERMIT FEE (Sub Total) Q
Civ C)
PLAN CHECKING FEE OM—'0001 2/ 1/Q6
Lender s Name 4617 1 AM 9 e 3Q
PERMIT ISSUING FEE � d
Lender s Address 0 0
I certify that I have read this application and under penalty of purlury 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
representatives of this County to enter upon the above mentioned property
for inspe rpose SEE REVERSE FOR EXPLANATORY LANGUAGE
SIG F R E DATE