HomeMy Public PortalAbout9719 RICHMOND WAY_Electrical__ WORKERS'COMPENSATION DECLARATION 10/81 APPLICATION FOR ELECTRICAL PERMIT
I �iere�y•affirtsy that I have a certificate of consent to self CE-806G
6 �j
insure, or a certificate of Workers'Compensation Insurance; COUNTY OF LOS ANGELES BUILDING AND SAFETY U
or a certified copy thereof(Sec. 3800, Lab. C:)
Policy No. 5520115 Company -CMW R RM FOR APPLICANT TO FILL IN JOB 9719 RICEMO11a MY
Certified copy is hereby furnished. New Residential Bldgs. &Pools
EACH NO. FEE ADDRESS
rMELE CM
Certified copy is filed with the county building inspec- 1 $2-Family, Sq. Ft.1819 $ —Is LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
Date 12-1-86 Applican s Residential Swimming Pools CROSS ST.
OWNER OR
FIRM NAME OWENS DEVfJ0PNEW
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL 2035
COMPENSATION INSURANCE ADDRESS
MMIUM
tThis section need not be completed if the work involved b First 20
he permit is for one hundred dollars($100)or less.) Y Total No. Additional CITY 1A Tel. No.338-2558
I certifythat in the performance of the work for which this PLAN CHECK
P 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
Applicant CITY Tel. No.
Date Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT JEEW'S E1. TC ' 11C.
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-CINIUM 11112-
with comply with such provisions or this permit shall be Top FAU —W.H. —
deemed revoked. Hood _ Fan _Other_ CITY RATDWM PATrK Tel. No.338-2558
LICENSED CONTRACTORS DECLARATION LICENSE OR
1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG. NUMBER 259475 Class. —
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCES D ate,'
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances ,1 O
Size 8 Type HP, KW, KVA, or KVAR f o 0
License Number 259475 —Lic. Class—AC-40— Up to 1 Incl. FINAL 6=
Over 1 to 10 Incl. DATE ✓ O
Contractor. Date 12-1-815 Over 10 to 50 Incl. FI VALI TION w
❑ I am exempt under Sec. Over 50 to 100 Inc. B
B.BP.C. for this reason Over 100 Z
Date: Services, Swbd., MCC&Panelboords
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V9 b 1 6 A
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V # 0 0 0 0 0 2
SINGLE FAMILY Temp. Power Pole&Appurtenances II o - 79,62
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 o ° ° 7 9 6 2 5
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 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
I certify that I have read this application and state that the TOTAL FEE 1k• 79.62
above information is correct. I agree to comply with all County
TAAJ
andStat aws regulating Electrical wiring, and
horize re sentatives of this County to enter upon
menti n property for inspection purposes.
`Z r� SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date