HomeMy Public PortalAbout9715 RICHMOND WAY_Electrical__ a urilOR�(ERS'COMPENSATION DECLARATION 76Ab63 10/81 APPLICATION FOR ELECTRICAL PERMIT
I h6F I,affi m that I have a certificate of consent to self CE'•BO6G
insure';'or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY 'ul
or a certified copy thereof(Sec. 380% Lab. C.)
Policy No. �So1 1� Company._$�.'E FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. EACH NO. FEE ADDRESS 9715 RICi1NOW V"
P y New Residential Bldgs. &Pools
In 7 9 LOCALITY
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. $ — $ CM
tion department. Multi-family Sq. Ft.* — NEAREST
Residential Swimming Pools CROSS ST.
Date 17-7—$fi ApplicantS Ff.FY'7'RTC__ P�NAMEnom'
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAILS n1
COMPENSATION INSURANCE ADDRESS.
(This section need not be completed if the work Involved by First 20
20,35 NUMB
the permit is for one hundred dollars($100)or less.) Total No. Additional CITY Nil Tel. No.359-3211
I certify that in the performance of the work for which this PLAN CHECKAPPLICANT -
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
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT MUM% E�TCr IW-
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 6 RD-
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked: Hood Fan _Other_ 77e
CITY RAT " PAS Tel. No.33.8-2558
_
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. _ Room Air Cond. Cl9475 as c—1 U
(commencing with Section 7000)of Division 3 of the Business 'DISTRICT.NO. PROCE BY t1.
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances
Size&Type HP, KW, KVA, or KVAR
License Number 2,994:7.9 Class G
��94 � —1n v Up to 1 Incl. FINALDATE „� . O
Over 1 to.10 Incl. VAU ATION E-^
Contractor s ate 12-1—Bra Over 10 to 50 Incl. FI W
❑ I am exempt under Sec. Over 50 to 100 Inc.
BAP.C. for this reason Over 100
Date: Services, Swbd., MCC&Ponelboards
0 -200 Amp. Under 600 V
Signature - 201 - 1000 Amp. Under 600 V 6 1 8.A
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. # o a o o�0 2
SINGLE FAMILY Temp. Power Pole&Appurtenances I ° o79.62
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's LicenseAdditional Sign Branch Circuits ° 6 ° 7 9 6 2 C5.
Law for the following reason (Section 7031.5, Business and
Professions Code): 1 2 2 4-8 6
❑ I, 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 petformance of the work for which this permit is issued PERMIT FEE (Sub-Total) 6902
(Sec. 3097, Civ. C..).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 1U 50
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 79.62
above information is correct. I agree to comply with all County
ad' anc s and State laws regulating Electrical wiring, and
hereby, thorize rep sentatives of this County to enter upon
th a ve-menti ne property for inspection:purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
-V Z2
Signature of Permittee , Date