HomeMy Public PortalAbout5837 AGNES AVE_Electrical_6/26/1989_outlet receptacles r
;/WORKERS COMPENSATION DECLARATION 76A663 10/81
PLICATION FOR ELECTRICAL PERMIT
171ereby affirm that I have a certificate,of consent to self insure CE 806G APPLICATION,
or a•certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C)
Policy No Company FOR APPLICANT TO FILL IN JOB
F-1New Residential Bldgs & Pools
Certified copy Is hereby furnished EACH NO FEE ADDRESS }
❑ Certified copy' is filed with the county building inspection 1 & 2 Family Sq Ft $ — $ LOCALITY
department Multi family Sq Ft — NEAREST '
ti CROSS ST
Residential Swimming Pools l,w OWNER OR
Date Applicant td<4� a \4 Q� �� FIRM NAME / _Z-)A--5/f r
14 CERTIFICATE OF EXEMPTION FROM WORKERSOutlets Rec Light/_SL�`/�� Sw,'` �t MAIL
f_f2 �r
COMPENSATION INSURANCE r ' ` First 20,, ADDRESS 54222 c
(This section need not be completed if the work Involved by the Total No Additional CITY L L G! Tel No
permit Is for one hundred dollars($100)or less)
PLAN CHEC
I certify that in the performance of the work for which this permit e APPLICANT K '
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
Date�f�"(L-7Apphcant x-- CITY � Tel No
�"
NOTICE TO APPLICANT If after making this Certificate Appliances Not Over 1 HPicate of PERMIT c �
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW _ APPLICANTJ Z
provisions of the Labor Code you must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS
provisions or this permit shall be deemed revoked - Top _ FAU _ WH _ ,
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_ CITY — G Tel No >0
I hereby affirm that I am licensed under provisions of Chapter 9 Disp — Room Air Cond _ s LICENSE OR Class
(commencing with Section 7000) of Division 3 of the Business and REG NUMBER -
Professions Code and my license Is in full force and effect Power Apparatus& Large Appliances d DISTRICT PROCESS BY
Size& Type HP KW KVA or KVAR
r
License Number Lic Class Up to 1 Incl FINAL �
Over 1 to 10 Incl
DATE -If
Contractor v� Date f VALIDATION 0
❑ Over 10 to 50 Incl -
H FINAL U
117-
I am exempt under Sec Over 50 to 100 Inc BY
Over 100 J CL
1.1
B&PC for this reason N
Services Swbd MCC& Panelboards� J-
Date ® Z
Date 0 200 Amp Under 600 V,S c'
Signature 201 1000 Amp Under 600 V H
❑ Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V
I a
SINGLE`FAMILY Temp Power Pole& Appurtenances 2
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit ' r t'144T b
I hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuits ACC °e
for the following reason (Section 7031 5 Business and Professions , � °
Code)
R1I as owner of the property will do the work and the structure Misc Conducts& Conductors , 1 ITM
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)
and Professions Code) 1 ®y r NOTAL 50 v 130
CONSTRUCTION LENDING AGENCY CHECK 50°0[I�
I hereby affirm that there is a construction lending agency for the CHANCE I °00
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total)
Civ C) -
s
Lenders Name 1
PLAN CHECKING FEE t_ �-i1Q[l1 6/26/$9
' , V 7
Lenders Address
PERMIT ISSUING FEE 4176 1 AM 9:16
S
1 certify that I have read this application and state that the above TOTAL FEE
information is correct I agree to comply with all County ordinances op
a
and State laws regulating Electrical wiring and hereby authorize
representatives of this County to enter upon the above mentioned
prop rty for inspection purposes r SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date