HomeMy Public PortalAbout9723 RICHMOND WAY_Electrical__ -Ae
hereby
affirm
that
COMPENSATION DECLARATION CE-806 10/81 Ar"PUCATOO �p per®® ELECTRICAL
n 2CT ICAL PERT
I hereby affirm that I have a certificate of consent to self CE-806G I� jJ�J FOR L�L� {�
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY lul
or a certified copy thereof (Sec. 3800, Lob. C.)
Policy No.550115 Company STA.L'Lr FIM FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. EACH NO. FEE ADDRESS
New Residential Bldgs. 8 Pools
97011711 RICEINUM WAY
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. 1$06 T—= $ 68.62 LOCALITY qEMP $
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Date 12-1-86 Applicant-� S ffi+�•r1111C. OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be ted if the work involved by Total No. Additional CITY Tel. Na359-3211
—2035 1011WR_
th®permit is for one hundreredd dollars($100)or less.)
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.
NOTICE TO APPLICANTT:: If,DateApplicant-after
Fixed Appliances Not Over 1 HP
er making this Certificate of PERMIT mss FT�`I'RTC IW.Exemption, you should become subject to the Workers' Range_ Heater_D.W. _ APPLICANT
Compensation provisions of the Labor Code, you must forth- Oven —Dryer _W.M._ ADDRESS 3876 D(�AliVII11G RD.
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. Hood _ Fan _Other_ CITY MTU&UN PARK Tel. N o
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. _ Room Air Cond. 259475 Class 4C 10
(commencing with Section 7000)of Division 3 of the Business Power Apparatus&Large Appliances DISTRICT N! r� PROC S BY a
and Professions Code,and my license is in full force and effect. a�( 0
Size&Type HP, KW, KVA, or KVAR Q
License Number 259475 Lic. Class_C-10 Up to 1 Incl. FINAL �
r Over 1 to 10 Incl. DATE 0
12-1-86 VALID IOM (—
Contractor S 1�+1 Date Over 10 to 50 Incl. FI W
❑ 1 am exempt under Sec. Over 50 to 100 Inc. iL
Over 100 N
B.BP.C. for this reason z
Date: Services, Swbd., MCC&Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 6 3 6
I hereby affirm that I am exempt from the Contractor's License ( o - 79. 1 2
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): 7 2 2 9-
-53
❑ I, as owner of the property, will do the work and the Misc. Conduits 8 Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ D
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) 68.62
(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 79.12
above information is corre I agree to comply with all County
ordinances a d State law egulating Electrical wiring, and
hereby ut ze represe to Ives of this County to enter upon
thea e, entioned p rty fo inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
ignafure of Permittee Date ��