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HomeMy Public PortalAbout5822AGNES AVE_Electrical (3) 's- -1%- WORKERS COMPENSATION DECLARATION CE 863 16ie1 APPLICATION FOR ELECTRICAL PERMIT I hereby affirm that I have a certificate of consent to self CE 8066 insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY or a certified copy thereof (Sec 3800 Lab C Policy 0ie�7 VV0&,,V1A/ FOR APPLICANT TO FILL IN JOB Certified co is hereby furnished EACH NO FEE ADDRESS ,J PY Y New Residential Bldgs 8 Pools ^ 1 8 2 Famil S Ft $ — S LOCALITY '� Certified copy is filed with the county bu ding inspec Y 9 — RS-4—tion department Multi family Sal Ft NEAREST `' ' Residential SwimmingPools CROSS ST a)&I /L) Date1ERT(FICATE Applicant FOONER OR R(Af NAME OF EXEMPTIO FROM WORKERS Z� MAIL Outlets Rec Light Sw_ e-� V COMPENSATION INSURANCE First 20 r !y ADDRESS (This section need not be completed if the work involved by Total No AddiTional CITY, Tel No 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 FixturesFirst 20 ADDRESS Total No '7// Additional CITY Tel 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 power Apparatus& Large Appliances DISTRICT NO PROCESSED BY and Professions Code and my license is in full force and effect O >. Size &Type HP KW KVA or KVAR C) License Number:7''07-1 ELic Class Up to 1 Incl FINAL V ` '� N Over 1 to 10 Incl DATE `� 7 S7� VALIDATION 0 Contract Date Over 10 to 50 Incl FINAL OO V ❑ I am exempt under Sec Over 50 to 100 Inc BY -- d B &P C for this reason Over 100 y Date '7 Services Swbd MCC & Ponelboardspoll- Z 0 200 Amp Under 600V ^�594,4A Signature 201 1000 Amp Under 600V 4ia o o o o 2 ❑ Over 1000 Amp or Over 600 V Exemption for Reg Maint Elect 2 0 0 1650 SINGLE FAMILY Temp Power Pole &Appurtenancess HOME OWNER BUILDER DECLARATION o `' o I Q 5 O Sign with One Branch Circuit I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits I Q 1 2-835 Law for the following reason (Section 7031 5 Business and Professions Code) ❑ I as owner of the property will do the work and the Misc Conduits& 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) D (Sec 3097 Civ C ) _ PLAN CHECKING FEE Lender s Name `O PERMIT ISSUING FEE Lender s Address I certify that I have read this application and state that the TOTAL FEE above information is correct I agree to comply with all County ordinances and State laws regulating Electrical wiring and hereby outho a representatives of this County to enter upon the above ntioned proper ction purpos s SEE REVERSE FOR EXPLANATORY LANGUAGE © 3 �3. Signature of Permittee Da