HomeMy Public PortalAbout5837 AGNES AVE_Electrical_4/1/1981_upgrade service amp MORrRS COMPENSATION DECLARATION
K 1 CE 806G (2 80) APPLICATION FOR ELECTRICAL PERMIT
'
insure
hereby affirm that I have certificate of consent to self COUNTY OF LOS ANGELES
insure or a certificate of Workers
rs Compensation Insurance or BUILDING AND SAFETY
a certified copy thereof'(Sec 3800 Lab C)
Policy No CompanFOR APPLICANT TO FILL IN ,JOB v�
y New Residential Bldgs &Pools' EACH NO FEE ADDRESS A/
E:1- Certified copy is hereby furnished 1 & 2 Family Sq, Ft $ — Is LOCALITY
❑ Multi family Sq Ft CROSS ST
Certified copy is filed with the county building inspection Residential Swimming Pools
department OWNER OR
FIRM NAME f
Date Applicant Outlets Rec_Light SW MAIL
AI LESS
First 20
CERTIFICATE OFlEXEMPTION FROM WORKERS Total No Additional CITY 34 No
COMPENSATION INSURANCE PLA C ECK }
CL
(This section need not be completed if the work involved APPLICANT 0
by the permit is for one hundred dollars ($100) or less) Lighting Fixtures First 20 ADDRESS U
Total No Additional X
I 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 p IT , W
so as to become subject to the Workers Compensation Laws Range_ Heater_D W APPLICANT
CL
Oven - Dryer_W M { ADDRESS z
Date•?1''' �� Applicant n Top _ FAU _W H 1,0 y 5-3 �r
Hood _ Fan _Other_ CITY Tel No of
NOTICE TO APPLICANT If after making this Certificate of Disp _ Room Air Cond_ LICENSE OR
Exemption you should become subject to the Workers REG NUMBER Class 3
Compensation provisions of the Labor Code you must forth Power Apparatus& Large Appliances DISTRICT NO PR S BY
with comply with such provisions or this permit shall be BY
with
deemed revoked Size&Type HP KW KVA or KVAR
Up to 1 Incl
FINAL
LICENSED CONTRACTORS DECLARATION _ Over 1 to 10 Incl DATE
Over 10 to 50 Incl VALIDA N
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc' BY
9 (commencing with Section 7000) of Division 3 of the Busi Over 100 y
ness and Professions Code and my license is in full force and 1
effect , Services 1/11 /���` > r
License Number-9(O?-r? Lic Class_' `� 0 200 Amp Under 600 V1/
201 1000 Amp Under 600 V
ContractorJRL P Date - I f Over 1000 Amp or Over 600 V
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractors Sign with One Branch Circuit
License Law for'the following reason (Section 7031 5 Busi Additional Sign Branch Circuits
Hess and Professions Code)
Misc Conduits&Conductors r J-9 4 6 0 8 A
I as owner of the property will do the work and the Other (See Complete Fee Schedule)—
structureJ is not intended or offered for sale (Section # 0 0 0 00 2
7044 Business and Professions Code)
CONSTRUCTION LENDING AGENCY 2 0 - 1950
1
I hereby affirm that there is a construction lending agency J
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) 0 4.0 1 —8 1
Lender s Address PERMIT ISSUING FEE \
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 J
ordinances and State laws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon
the ab a mentioned proper for i spection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
� r
Signature of PermittKe Date J,F
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