HomeMy Public PortalAbout9727 RICHMOND WAY_Electrical__ 1
WORKERS'COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR 9LECTRICA` PERMIT I�hereby Offirm that I have a certificate of consent to sel� CE-806G �`" i`& I5 l� !I`77�
rrpkre, or a certificate of Workers'Compensation Insurance,, COUNTY OF LOS ANGELES BUILDING AND SAFETY
of a certified copy thereof(Sec. 3800, Lab. C.) IJ
Policy No.550115 Coinpany._SUM FUND FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished, W
EACH NO. FEE �1ID AY
New Residential Bldgs. 8 Pools ADDRESS 9703 RIC
Certified copy is filed with the county building inspec-, 1 &2-Family, q•S Ft. 2026 $ — $ LOCALITY
tion department. Multi-family Sq. Ft. — NEAREST TEDME
CROSS ST.
Date 12-1-8� Applicant ERRVsS T�f.T�"792f Residential Swimming Pools OWNER OR
CERTIFICATE OF EXEMPTION FROM WORKERS' ; FIRM NAME
Outlets: Rec Light Sw._ , MyRr�.F.
COMPENSATION INSURANCE ADDRESS 2035
(This section need not be completed If the work involved by First 20 .
Total No. Additional , CITY Tel. No.
the permit is for one hundred dollars($1100)or less.) —
I certify that in the performance of the work for which this: PIAN CHECK
permit is issued, I shall not employ any person in any manner. APPLICANT
so as to become subject to the Workers'Compensation Laws.: Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT mss$ FTFY'PRTC
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 D010UM RD.
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked.' Hood Fan _Other= CITY BATafm PARR Tel. lvo.338-255
LICENSED CONTRACTORS DECLARATION _
'I LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 , Disp. _ Room Air Cond. REG. NUMBER 259475 Class. C-10,
(commencing with Section 7000)of Division 3 of the Business; power Apparatus&Lar e Appliances ' DISTRICT NO.. l '/ PR?=Y
BY
and Professions Code,and my license is in full force and effect..I pP g pp (/J' �U( C1
Size&Type HP, KW, KVA, or KVAR
License Number 25947% Lic. Class 19 Up to 1 Incl. FINAL
��
s
Over 1 to 10 Incl. DATEVALID T N Cy
Contractor a �s 7�' emote 12-1-86 Over 10 to 50 Incl. I FIN ' Cy W
I am exempt under Sec. Over 50 to 100 Inc. BY ,
B.&P.C. for this reason Over 100 Z,
Date: Services, Swbd., MCC&Panelboards w
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. I
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION !
Sign with One Branch Circuit I
I hereby affirm that I am exempt from the Contractor's License i Additional Sign Branch Circuits - 87.48
Low for the following reason (Section 7031.5, Business and $71 4 8 U
Professions Code):
o o o =
I Misc. Conduits&Conductors i
I, as owner of the property, will do the work and the 1 2 2 4;�8 b
structure is not intended or offered for sale (Section j Other(See Complete Fee Schedule)_
7044, Business and Professions Code). ,
CONSTRUCTION LENDING AGENCY
I hereby offirm that there is a construction lending agency for
the performance of the work for which thisermit is issued
P PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). j
PLAN CHECKING FEE
Lender's Name i
PERMIT ISSUING FEE 10.50
Lender's Address
I certify that I have read this application and state that the 1 TOTAL FEE
above information is correct. I agree to comply with all County
ordinance nd State I s regulating Electrical wiring, and 4
hereby orize repre tatives of this County to enter upon
the a-mtion d r perty f r inspection purposes.- I SEE REVERSE FOR EXPLANATORY LANGUAGE
Si nature of Permittee Date ,