HomeMy Public PortalAbout9708 RICHMOND WAY_Electrical__ WORKERS'COMPENSATION DECLARATION CE.Bo6 10/81 APPLICATION
TION F R ELE CYROCAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-� 6� A`� IJP ®li'!® 9
insure, or a cgrtificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No.550115 Company SIM FUND
FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs. &Pools
9708 Ricolm MY
1 &2-Famil 819 $ — $ 69 LOCALITY
Certified copy is filed with the county building inspec- y, Sq. Ft. 1819
tion department. Multi-family Sq. Ft. — NEAREST
t Residential Swimming Pools CROSS ST.
'
Date 12-1-86 Applicant -r TTI ' ; flRWNER OR
M NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Li ht Sw._ MAIL
COMPENSATION INSURANCE g First 20 ADDRESS 2035 MIYRIME
(This section need not be completed If the work involved by Total No. Additional CITY N�tOVIA Tel. No.359-3211
the permit Is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this APPLICANT
permit 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
CITY Tel. No.
Date opplicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT s
Exemption, you should become subject to the Workers' Range_ Heater_D.W.
Compensation provisions of the Labor Code, you must forth- Oven —Dryer _W.M.— ADDRESS 3876 DOWNING RD.
with comply with such provisions or this permit shall be Top — FAU —W.H. —
deemed revoked. Hood _Fan _Other— CITY wafm PARK Tel. N-338-2558LICENSED CONTRACTORS DECLARATION LICENSE OR
1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG.NUMBER Class.
(commencing with Section 7000) of Division 3 of the BusinessDISTRICT NO PRO S D BY
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances K d.'
Size&Type HP, KW, KVA, or KVAR 1�V
V
License Number 55()115 Lic. Class C 10 Up to 1 Incl. FINAL
n Over 1 to 10 Incl. DATE Contractor `� S �� Date 12-1-86 7�04
1 - Over 10 to 50 Incl.
By
I am exempt under Sec. Over 50 to 100 Inc. BY O.
B.&P.C. for this reason Over 100 Z
Date: Services, Swbd., MCC&Ponelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and ;2 6 1 7. 1 A
Professions Code): # 0 0 0 0 0 2
I, as owner of the property, will do the work and the Misc. Conduits&Conductors i o 0 T
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_
7044, Business and Professions Code). ) G 2 8 6
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 10 50
Lender's Address
1 certify that I have read this application and state that the TOTAL FEE
above information is correct. I agree to comply with all County
ordinances and Stateaws regulating Electrical wiring, and
hereby thorize repr entatives of this County to enter upon
the mentio a roperty for inspection purposes.
/Z � SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date