HomeMy Public PortalAbout4846 AGNES AVE_Electrical_9/12/2019_APPLIANCES WORKERS COMPENSATION DECLARATION CE 806 10181 APPLICATION FOR ELECTRICAL PERMIT [L2J��
I hereby affirm that 1 have a certificate of consent to self Insure CE 9oeG `J
or a certificate of Workers Compensation Insurance or a Certified COUNTY OF LOS ANGELES ' BUILDING AND SAFETY
copy thereof(Sec 3800 Lab C) IF
Policy No Lj f x It i j Company f f ' FOR APPLICANT TO FILL IN JOB �.f /� Ll I /
❑ Aj
Certified co is hereby furnished W Y EACH NO FEE ADDRESS l + fJ /'7 ''7
PY Y New Residential Bldgs & Pools
4❑ Certified copy is filed with the county building inspection 1 & 2 Family Sq Ft $ — $ LOCALITY
department I Multi family Sq Ft t — NEAREST
I" ,y Ir,(^ ' ."' CROSS ST U L. ) E ; <Q,,, A
Date Applicant Residential Swimming Pools OWNER OR
PP ^ FIRM NAME I? L
CERTIFICATE OF EXEMPTION FROM WORKERS jMAIL
COMPENSATION INSURANCE Outlets Rec—Light —Sw ADDRESS
(This section need not be completed if the work Involved by the First 20
permit is for one hundred dollars($100)or less)
Total No Additional CITY T-r m 7 b, C ^� Tel No
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
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 i
Total No Additional
Date Applicant CITY r1 Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT EF
Exemption you should become subject to the Workers Compensation Range_ Heater_ DW _ APPLICANT i r t tre
provisions of the Labor Code you must forthwith comply with such Oven _ Dryer_ W M _ ADDRESS )6 (r L I'll
provisions or this permit shall be deemed revoked Top _ FAU _ WH
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ i CITY C—I), !f Tel No p I
I hereby affirm that I am licensed under provisions of Chapter 9 Disp — Room Air Cond RN f" y� Class �� )
(commencing with Section 7000)of Division 3 of the Business and REEGGNUMBER w` o� t7
Professions Code and my license Is in full force and effect Power Apparatus& Large Appliances DISTRICT NO PROCESSED BY 1
Size&Type HP KW KVA or KVAR V W
License Number Lic Class f t h Up to 1 Incl (�#. FINAL —J
1 "' Over 1 to 10 Incl
Contractor Date DATE i VALIDATION �
E] Over i10 to 50 Incl FINAL
I am exempt under Sec Over 50 to 100 Inc By
B&PC for this reason Over 100
Services Swbd MCC&Panelboards ,
Date 0 200 Amp Under 600 V W
Signature 201 1000 Amp Under 600 V
❑ Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V z
SINGLE FAMILY Temp Power Pole& Appurtenances w
HOME OWNER BUILDER DECLARATION Sign with One Branch Circuit R f a
I hereby affirm that I am exempt from the Contractors License Law m I a,
for the following reason(Section 7031 5 Business and Professions Additional Sign Branch Circuits r.,
Code) �
a ! f i
y Misc Conduits&Conductors t [><
I as owner of the property will do the work and the structure
is not intended or offered for sale (Section 7044 Business Other(See Complete Fee Schedule) foray
i t and Professions Code) M 1
, ) folie t
CONSTRUCTION LENDING AGENCY
hereby affirm that there Is a construction lending agency for the 447tjti{A€>
erformance of the work for which this permit is Issued(Sec 3097 PERMIT FEE (Sub Total)
IV C) P
y PLAN CHECKING FEE ({ ; (fir + t1�yF �t
Lenders Name yF
PERMIT ISSUING FEE �tt1'mfg !b7 D
Lenders Address
I certify that I have read this application and state that the above TOTAL FEEj
Information Is correct I agree to comply with all County ordinances i
and State laws regulating Electrical wiring and hereby authorize j ro d
represQntatives of this County to enter upon the above mentioned
propeft�f�� tegion pur sea f t r/ SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date