HomeMy Public PortalAbout9801 RICHMOND WAY_Electrical__ WORKERS'COMPENSATION DECLARATION 78-683 10/81 APPLICATION FOR ELECTRICAL PERMIT
hereby affirm that I have a certificate of consent to self insure, CE-ei aG
or a certificate of Workers' Compensation Insurance, or a certified I COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.) I
Policy No. Company FOR APPLICANT TO FILL IN JOBADDRESS ��� a h [�
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
❑ 1 & 2-Family,S Ft. $ _ $ LOCALITY , M#f(P
Certified copy is filed with the county building inspection y, q . p
department. Multi-family Sq.Ft. NEAREST 1Ge.� Ua ?d
Residential Swimming Pools CROSS O
Date Applicant OWNER OR
FIRM NAME Ci0
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL �
COMPENSATION INSURANCE O�tlets:Rec—Light—Sw.— ADDRESS feV` 6t Zr
(This section need not be completed If the work Involved by the I First 20
permit is for one hundred dollars($100)or less.) �J
Total No. Additional CITY MI,yd�(y'= 1'r-Y Tel.No.�l�a31 a
I certify that in the performance of the work for which this permit APPLICANPLAN,CHT
CK -G`'1°�
is issued, I shall not employ any person in any manner so as to , APPLICANT L �4 0
become subject to the Workers`Compensation Laws. Lighting Fixtures First 20 ADDRESS
r Z CIV A ^r lk 6 k �C 'Notal No. CITY Tel.No.Additional
C7'
Date ., Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT r
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ APPLICANT 6+64
provisions of the Labor Code,you must forthwith comply with such 10ven _ Dryer _ W.M._ ADDRESS to Q b Q)o Z dr
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ CITY'—5M JOi–AEC, Pel.No. 2_Ysv _7f
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ 6 1
I hereby affirm that I am licensed under provisions of Chapter 9 LICENSE OR C
(commencing with Section 7000)of Division 3 of the Business and Disp. — Room Air Cond. REG.NUMBER G�� Class.
Professions Code,and my license is in full force and effect. POJ r Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
�/ Size&Type HP,KW,KVA,or KVAR �e•°%9 Q
License Number C–L60!a6-L Lic.Class Up to 1 Incl. FINAL V
tOver 1 to 10 Incl. DATE VALIDATION
ContractorAl- �(B C�-J G Date 1&'--'LL(��O O
Over 10 to 50 Incl. FINAL V
❑ I am exempt under Sec. Over 50 to 100 Inc. gY OW.
Over 100 N
B.&P.C.for this reason
0-2– p Ser�iceS,Swbd.,MCC&Panelboards
Date: 1 0-200 Amp.Under 600 V G/
Signature 201 - 1000 Amp.Under 600 V "
Over 1000 Amp.or Over 600 V
❑ Exemption for Reg.Maint.E ect.,
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit °g
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits w CT
for the following reason(Section 7031.5,Business and Professions
Code): 7;a1_i7 115.511 1
Mise.Conduits&Conductors T }�7
❑ I,as owner of the property,will do the work and the structure I ITEMS,
Is not intended or offered for sale (Section 7044, Business Othgr(See Complete Fee Schedule) _
and Professions Code). 1 ® TOTAL 115 .50
-
CONSTRUCTION LENDING AGENCY I CHECK 115.5:1'
1 hereby affirm that there is a construction lending agency for theZ
Performance of the work for which this permit is issued(Sec.3087, PERMIT FEE (Sub-Total) „j CHANGE ■011.
Civ.C.).
PLAN CHECKING FEE
Lender's Name
PER ISSUING FEE
Lender's Address 1 3491 1 AM 10:2-3
1 certify that I have read this application and state that the above TOTAL FEE
information is correct.I agree to comply with all County ordinances
and State laws regulating Electrical wiring, and hereby authorize i
representatives of this County to enter upon the above-mentioned
Property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee. Date