HomeMy Public PortalAbout5822AGNES AVE_Electrical (2) WORKERS COMPENSATION DECLARATION 63
tE806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
8
I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or /
a certified copy thereof(Sec 3800 Lab C)
Policy No XI-5-1 � 2n5 r_776{� tJeCt- FOR APPLICANT TO FILL IN JOB
�tY1au Company Q PjVlf
New Residential Bldgs &Pools EACH NO FEE ADDRESS
i Certified copy is hereby furnished 1 &2 Family Sq Ft $ — $ LOCALITY
Multi family Sq Ft NEAREST
Certified copy is filed with the county budding inspection CROSS ST
department R Residential Swimming Pools OWNER OR
FIRM NAME
Date Q J�Apphcant( Outlets Rec_Light Sw MAIL
First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS Total No Additional CITYTel No JA Z(-*
}
COMPENSATION INSURANCE d
PLAN CHECK + 0
(This section need not be completed if the work involved APPLICANT U
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS t>`
Total No Additional
1 certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY Tel No 0
permit is issued I shall not employ any person in any manner } PERMIT
so as to become subject to the Workers Compensation Laws Range_ Heater_D W APPLICANT 71 a
Oven _ Dryer_W MADDRESS to
3310 A, 1 Z
(Date Applicant Hood _ Fan —Other JLICENSE
CITY WAT aTel No Sd 3NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ OR
d
L Exemption you should become subject to the Workers 'AEG NUMBER 310ISSI Class
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PRO CE SED BY
with comply with such provisions or this permit shall be
deemed revoked Size&Type HP KW KVA or KVAR 4t / 0?
Up to 1 Incl f 0�
FINAL
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl DATE /D ►�' VALIDATION
Over 10 to 50 Incl
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL
9 (commencing with Section 7000) of Division 3 of the Busi Over 100 BY
ess and Professions Code and my license is in full force and
effect Services
License Number 3)aSS Lic Class bio&V 0 200 Amp Under 600 V Ef Y V3
201 1000 Amp Under 600 V
Contractor(,F_/1 jEAEl2GSr Date 7^97 -X3 Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances 240 1 5A
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit #! o 0 0 0 o Z
License Law for the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
ness and Professions Code) k
Misc Conduits&Conductors 21- o 1 8,50
I as owner of the property will do the work and the Other (See Complete Fee Scheduler o 0 0 1 8 5 0
structure is not intended or offered for sale (Section
60
7044 Business and Professions Code) o727-83
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
for the performance of the work for which this permit is PERMIT FEE (Sub Total)
issued (Sec 3097 Civ C)
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee)
Lender s Address PERMIT ISSUING FEE f'C)
I certify that I have read this application and state that the TOTAL FEE o
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
7'n A-, -)-a1-V)
Signature of Permittee Date