HomeMy Public PortalAbout9726 RICHMOND WAY_Electrical__ �. ,affirm that
COMPENSATION DECLARATION C W6G 10/81 APPLICATION FOR ELECTRICAL PERMIT
.1 liffreby affirm that I have a certificate of consent to self
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec. 3800, Lob. C.)
Policy No. 5SO115 Company MM FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS 9704 RIC 40ND WAY
44 Certified copy is filed with the county building inspec- I 1 &2-Family, Sq. Ft.._M30 $ — $ 63 .94LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST
CROSS ST.
IF�21QVs i2fTW!M Residential Swimming Pools OWNER OR
Date 12-1-86 _Applicant_k $ s FIRM NAME
f14FaZq 1119M
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw.._
COMPENSATION INSURANCE ADDREss 2035 NNR=
(This section need not be completed if the work involved by First 20
the permit is for one hundred dollars($1100)or less.) Total No. Additional CITYWONROVIA Tel. No.338_2558
PLAN CHECK `
1 certify that in the performance of the work for which this 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
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT s
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 DOfl11r1M RD.
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY Tela No
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ PARR 338-2558
Dis _ Room Air Cond. LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 p' REG. NUMBER 259475 Class.0 11 0
(commencing with Section 7000)of Division 3 of the Business Power Apparatus 8 Large Appliances DISTRICT NO. PRO D BY a
and Professions Code,and my license is in full force and effect.
Size&Type HP, KW, KVA, or KVAR'
License Number959470i Lic. Class 117-11(111 Up to 1 Incl. FINAL (�
Over 1 to 10 Incl. DATE O
Contractor CRY S - Date �2-1-86 VALI TION
Over 10 to 50 Incl. FINACA
❑ �.
i am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C. for this reason Over 100 U)
Date: Services, Swbd., MCC&Panelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
SINGLE FAMILY Temp. Power Pole&Appurtenances 6 1 7.3 AHOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits # 0 0 0 0 0 2
Low for the following reason (Section.7031.5, Business and
Professions Code): 1' - 7244
❑ 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)_ ® c 0 0 7 2 4 4 5
7044, Business and Professions Code). 2 2 4=8 b
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.). QA
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 10
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 72.4
above information is correct. I agree to comply with all County
ordinances and Stat laws regulating Electrical wiring, and
hereb authorize re sentatives of this County to enter upon
the ve-menti propert for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature•of Permittee Date