HomeMy Public PortalAbout4846 AGNES AVE_Electrical_7/6/1989_OUTLETS a
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` Rhat I COMPENSATION DECLARATION CEAao6G iDiBi APPLICATION FOR ELECTRICAL PERMIT )
pceb}affirm that I have a certificate of consent to self insure
r a certificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY +
gogy thereof(Sec 3800 Lab C) ��.e//+� o
Policy N-422 Company L!� Q • `^^� FOR APPLICANT TO FILL IN JOB
Ir" +Certi'md Lopy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ADDRESS
TTT"` { $ _ $ LOCALITY
❑ Certified copy is filed with the county budding inspection 1 & 2 Family Sq Ft —
departme t Multi family Sq Ft �-+ NEAREST
I rl CROSS O
s '>'1 L C Residential Swimming Pools OWNER OR
Date Applicant
2 FIRM NAME ti I
r I CERTIFI AT OF EXEMPTION FROM WORKERS Outlets Rec J Light Sw' Z +'+ x MAIL r
j COMPENSATION INSURANCE Qe ADDRESS s s
First 20 +
(This section need not be,,completed If the work involved by the Y CITY Tel No
permit Is for one hundred dollars($100)or less) Total No Additional
I certify that in the performance of the work for which thistpermit } V f r PLAN CHECK + t
APPLICANT
is issued I shall not employ an t
y person in any manner so as to
become subject to the Workers Compensation Laws Lighting Fixtures First 20ADDRESS
+ r ° Total No L Additional "s Y
Date Applicant CITY Tel No
t
Fixed Appliances Not Over 1 HP o PERMIT ff..,�...
NOTICE TO APPLICANT If after making this Certificate of APPLICANT
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW _ _
provisions,.of the Labor Code you must forthwith comply with such Oven _ Dryer _ W M _ ADDRESS
-,provisions ort this permit shall be deemed revoked Top _ FAU _ WH _ I
o. SLICENSED CONTRACTORS DECLARATION + _ Tel No, Z _ a
Hood � Fan _ Other_ CITY p
I hereby affirm that I am licensed under provisions of Chapter 9 Disp Room Air Cond LICENSE OR CIa s
(commencing with Section 7000)of Division 3 of the Business and REG NUMBER
Professions Code and my license is in full force and effect DISTRICT NO PROCESSED BY
Power Apparatus&Large Appliances �� O
+ Size&Type HP KW KVA or KVAR O
r (�
License NumppbeerlT��iZ Lic Class Up to 1 Incl + FINAL
Ilorwa n �1YM Date d (� 4 Over 1 to 10 Incl a DATE t,fi M VALIDATION O
Contractor-
❑ oma.r-.r Over 10 to 50 Incl FINAL U / V
I am exempt under Sec Over 50 to 100 Inc BY F i s W
B&PC for this reason Over 100 Z
Services Swbd MCC&Panelboards -
Date L 0 200 Amp Under 600 V
Signature 201 1000 Amp Under 600 V W r
Over 1000 Amp or Over 600 V S
Exemption for Reg Maint Elect - ,k
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SINGLE FAMILY I I Temp Power Pole& Appurtenances fi
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit - v �w�+ T
I hereby affirm that I am exempt from the Contractors License Law Additional Sign Branch Circuits +r +a ACCT Q
for the following reason(Section 7031 5 Business and Professions
Code) I + S 3307 - 1s 00
Misc Conduits&Conductors❑ T Com+I as owner of the property will do the work and the structure 1 iT61 h7 a
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule)
and Professions Code) polo, TOTAL 18.00
CONSTRUCTION LENDING AGENCY - v OECK 18.00
I hereby affirm that there is a construction lending agency for the i INK �y
performance of the work for which this permit is issued(Sec 3097 PERMIT FEE (Sub Total) W
Civ C) i a
PLAN CHECKING FEE - ��4 '/ LV,6/89Lenders Name t 0000-Ml
v PERMIT ISSUING FEE � T /Q d
Lenders Address
43O 1 t AM11 45
1 certify that I have read this application and state that the above TOTAL FEE o
information is correct I agree to comply with all County ordinances
and State laws regulating Electrical wiring and hereby authorize .. d
representatives of this County to enter upon the above mentioned
property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
gRtszz!�N hF, -
Signa of P r ttee Dba
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