HomeMy Public PortalAbout9722 RICHMOND WAY_Electrical__ 86
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COMPENSATION DECLARATION CE-806 10/81 �I@ PLIC/,�Y�ON FOR ELECTRICAL
PERMIT I hrt��affirm that I have a certificate of consent to self CE-806G 6�r IIf�" b'� I7 1;5 ti 1R �s 6'- ®l`9® Ql '
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES B IL01611G AIND SAFETY
or a certified copy thereof(Sec. 3800, Lab. c.)
Policy No.550115 Company_CPA'LT FUND FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS MY
Certified co is filed with the count building p y q• 1942 $ —is LOCALITY
copy y gins ec- 1 &2-Family, S Ft. O
tion department. Multi-family Sq. Ft. — NEAREST
12-1-86 J� $
sS BC. Residential Swimming Pools
CROSS ST.
Date Applicant 'FIOR
FIRM NAME OWFM D9VFTDEVE FP
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL.
Outlets: Rec Li ht Sw._
COMPENSATION INSURANCE g ADDRESS 2035 MYRTLE
(This section need not be completed if the work Involved by First 20
the permit is.for one hundred dollars(s100)or less.)
Total No. Additional CITY manx7im Tel. No359-3211
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
Date Applicant CITY � Tel. No.
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT JEEW'S ELBC !RIC 11 C.
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 DOWNIM RD.
with comply with such provisions or this permit shall be Top FAU —W.H:—
deemed revoked. O
CITY BATON ppm Tel. tvo338-2558
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ 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 NCS PROCE Y >and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances 5� dC/ a
259475 Size&Type HP, KW, KVA, or KVAR• CC
License Number Lic: Class!C_=10 Up to 1 Incl. FINAL CJ
Contractor
SIS • 12-1:86 Over 1 to 10 Incl. DAT Vp TION O
❑ Over 10 to 50'lncl. FIN
1 am exempt under Sec. Over 50 to 100 Inc. B X�% LJ
' a
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. Ma.int. Elect. Over 1000 Amp, or Over 600 V
SINGLE FAMILY Temp. Power Pole&Appurtenances 61 7 5 A.
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuito 0 0 0 0 2'
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 ) o - 84.29
Professions Code):
❑ 1, as owner of the property, will do the work and the Misc. Conduits&Conductors o - 81L296
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ 1 2 2 4-8 6
7044, Business and Professions Code). PO
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.). 73
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 84.29
above information is correct. I agree to comply with all County
ordinan es and S laws regulating Electrical wiring, and
hereby thorize re esentatives of this County to enter upon
the a-menti I
ne propert for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Z �
Signature of Permittee Date