HomeMy Public PortalAbout4846 AGNES AVE_Electrical_9/18/1989_SERVICE AMP � t {
WORKERS COMPENSATION DECLARATION +7BA663 10/81 t — --
t �Ii(iE[eby affirm that I have a certificate of consent to self insure CE 806G r(} APPLICATION FOR ELECTRICAL PERMIT' t
or a`�1SfCC ificate of Workers Compensation Insurance or a certified COUNTY OF LOS ANGELES ' BUILDING AND SAFETY +,
cdpy,thereof(Sec 3800 Lab C)
r-,
Policy No - mpany . . �T FOR APPLICANT TO FILL IN JOB
1. ADDRESSt y t� r
E]] Certified copy Is hereby furnished + New Residential Bldgs & Pools . EACH^ NO FEE
t r f - r 't LOCALITY r x
❑+ Certified copy is filed with the county budding inspection 1 & 2 Family Sq 9F r_1
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department> J t ' Multi family Sq"Ft t r — NEAREST CROSS ST �
^s1� e
-I '' Residential Swimming Pools 1 OWNER OR(, H
Date Applicant
Fx *7 FIRM NAME A
CERTIFICATE OF EXEMPTION FROM WORKERS r' WAIL
► >
� Outlets Rec—Light— Swk"i + ; ADDRESS �o 4t k f COMPENSATION INSURANCE b+, + (9
t (This section need not be"completed If the work involved by the r t I First 20 CITY i '"�`° Tel No
permit is for one hundred dollars($100j or less) .1,, t ' }Notal No Additional } i
s $ S F �a PLAN CHECK , {t 1 ti 1 t
I certify that in the performance of the work for which this permit ' {� y 1 t 1 -r APPLICANT w e
is Issued I shally not employ any person_n any manner so as to
becomessubject to the Workers Compensation Laws Lighting Fixtures Forst 20I ADDRESSt t rs i Arta + b f e
~7 ) { u r I f 4 Total No ' r Additional i r CITY x f r Tel No d Ir ~ r
Date Applicant M
Fixed Appliances Not Over 1 HP PERMIT
.�rNOTICE¢ TO APPLICANT If after makings this Certificate of ` t t I
Exem Ion f M t i APPLICANT -e /r
pt you should become subject to the Workers Compensation Range— Heater_ DW
a
provisions of the Labor, Coder you must forthwith comply with such On Dryer— W M�_ ' ADDRESS (? Sa i e
n provisions or this permit shall be deemed revoked To FAU WH
y
4t� a� w r pr «r— A 4 r CITY t Tel No "
LICENSED CONTRACTORS DECLARATION Hood — Fan — Other l e t r 4 e N s +r e
I hereby affirm that I>'am licensed under provisions ofR Chapter 9 t*Dosp — Room Air Cond REG NUMBER (') t CI
P r (commencing with Section 7000)of Division?3 of the Busonessrand e % j / > r a
s Professions Code and my'locense Is in full force and effect* power Apparatus& Large Appliances r e r DISTRICT NO tr - F PROCESSED BY
L rf 4t. 11 a r asW Sow°&t Type HP KW KVA or KVAR 1 i 484
w 'License Number !" f> Lic Class r I —i Up to 1 Incl FINAL /lam { s4 `'
ai t t 4 ~ r 4 a Over 1 to 10 Incl M DATE ' /` �l r,�/ w VALIDATION it Q{e
t Contractor c Date + a ti Incl
! ( {j r !
❑ y Over 10 to 50 t a FINAL „ i r
I am exempt under Sec A Over 50 to 100 Inc B } p LLI
3 '�
S B&P C for this reason rA w # > r y Over 100! d 4 i N
S iServices�Swbd MCC&Panelboardsa ` ' Z
®
Date 0 200 Amp Under 600 V 4
Signature µ > t 1x 201 1000 Amp Under 600 V a " Mr +a t v s W q �r
t t
~*'>,. I I L Over 1000 Amp or Over 600 V r r a
k Exemption for Reg Maint Elect y � ; 1 � d ,
T a
SINGLE FAMILY Temp Power Pole&Appurtenances r t t x1 r ►2 1 10 ,t
xF it hereby affirm Othat0I am exempt BUILDER
om the Contractors License Law w Sign with One Branch Circuit i�,, PAZ,, + ACCT I i i ti
for the following reason(Section 7031 5 Business and Professions s -4 Additional Sign BranchjCircuots t t r ( o�
4.k Code) .t yt �` ! Y s i � i� +�.}, t�11 � 6 t4r
❑ t r A fi > Misc Conduits&Conductors d x it "' v s
I as owner of the property/`woll do the work and the structure J iw 1t $ ;} + v
is notdmtended or offered for`sale (Section 7044 Business µOther(See Complete Fee Schedule) ► 5 1� .4 i } ¢ { Jq
and#Professions Code) a n s �"� �— r + T�Tp{- s 1. a.'�m�� v
8 R CONSTRUCTION LENDING AGENCY �. r j r Y t b 1t4fiG4ft� y� 14 .R7
I hereby affirm that there is a construction lending agency for the r 1 '4 ! � 4 � ' y t00
p performance of the work for which this permit is issued(Sec 3097 PERMIT FEE h a 1(Sub Total),j^^ d S r '
i Civ C) t t r r a r {✓� r °' t-
o
i o1 t %4 > a yPLAN CHECKING FEE) a r
Lenders Name t
r PERMIT ISSUING FEE r ��G w� +�
# 1 r t v • 5�Jdd ri Sj, d ,J!1. a 1 t AM 8 12
Lenders Address )t t x-. ? r t s }
I certify that ly have read this application and statethat the above TOTAL FEES ' +S 5 LI r
'information istcorrect I agree to comply with+all County ordinances
and State laws regulating Electrical wiring and hereby authorize s a + yet 9 ' # ti • t y A
repre ntatives of this County to enter upon the above mentioned
d p r for inspection puri2oses t a r
SEE REVERSE FOR EXPLANATORY LANGUAGE
gn ture of Permitte6 Date x s
t 1 �