HomeMy Public PortalAbout9714 RICHMOND WAY_Electrical__ YIffirm that
COMPENSATION DECLARATION CE-806 10/81 APPLICA® I®Il�.l ��OR ELECURICAL PERMIT
G�.herebyaffirm that I have a certificate of consent to self CE-806G �r ® ll�l L� �e
tnsure'`or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGEUS BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lob. C.)
Policy No. ��t9TTCompany FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bidgs. &Pools
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. 1942 S .038 —Is 73 797 LOCALITY TgypLE
tion department. I Multi-family Sq. Ft. — NEAREST
F+ pp Residential SwimmingPools CROSS ST..
Date 77-7—N
-Applicant s- EESCE2T['_ _ OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec Light SwMAIL
COMPENSATION'INSURANCE ._ ADDRESS 2035 MZR ZS
(This section need not be completed if the work involved by First 20
the permit is for one hundred dollars($100)or less.) Total No. Additional CITYNCMMZIA Tel. No.359_3913
I certify that in the performance of the work for which this PLAN CHECK
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 Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after. making this Certificate of APPLICANT
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 D( G RD.
with comply with such provisions or this permit shall be Top — FAU _W.H. —
deemed revoked. CITYIRAT77sT1N Tel. 1J0-
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ PARK 33 — 5
p'
Dis _ Room Air Cond. LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 REG.NUMBER 259475 Class.C-10
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCE BY
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances �^ ,J p„
Size 8 Type HP, KW, KVA, or KVAR J i(/OY .V
Lbut, icense Number 259475 Lic. Class C 10 Up to 1 Incl. FINAL
Contractor s Date 12 1 86 Over 1 to 10 Incl. DATE f3�'� VAL9DA ON
Over 10 to 50 Incl. jnLd W.
❑ I am exempt under Sec. Over 50 to 100 Int.
BAP.C. for this reason Over 100 U)
Date- Services, Swbd., MCC&Ponelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1.000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. Q
SINGLE FAMILY Temp. Power Pole&Appurtenances # L
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit o o 8 k 2 9
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits o 0 0 $4,2 9_
Low for the following reason (Section 7031.5, Business and 0
Professions Code): 2 2 G i$t5
1:3I, as owner of the property,will do the work and the Misc. Conduits$Conductors'
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_
7044, Business and Professions Code).
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.). 7.
PLAN CHECKING FEE
Lender's Name
Lender's Address PERMIT ISSUING FEE 1113_5(
I certify that I have read this application and state that the TOTAL FEE 84
above information is c rrec I agree to comply with all County
ordinances and Stat laws regulating Electrical wiring, and
hereby a onze re resentatives of this County to enter upon
the mentio d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Imo► /�'Z��
Signature of P miftee Date