HomeMy Public PortalAbout9802 RICHMOND WAY_Electrical__ WORKERS'COMPENSATION DECLARATION 78-663 10/81 APPLICATION
FOR ELtCTRICA PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE-806G L� i.+ �q Il V f'1 ^I� II�Y�
or a certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.) fl
Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is hereby furnished. EACH NO.. FEE ' ADDRESS
New Residential Bldgs.&Pools � LOCALITY � j
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. f B!J $ _ $ �;In fie e_ $
fy
department. Multi-family Sq.Ft. NEAREST e�,} `` �__-- --A,y ?
Residential Swimming Pools CROSS ST jg �° C llr
Date Applicant OWNER OR
FIRM NAME a
CERTIFICATE OF EXEMPTION FROM WORKERS` Outlets:Rec—Light_Sw.— MAIL
COMPENSATION INSURANCE ADDRESS P10
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CITY �� �` Tel.N . ?f�
I certify that in the performance of the work for which this permit I PLAN CHECK��i
is issued, I shall not employ any person in any manner so as'to APPLICANT �v .&O
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Additional
10�—010 Total No. CITY Tel.No.
Date Applicant Gd�1� Fi I��V�'e G� Fixed Appliances Not Over 1 HP PERMIT 6'.14{•�
NOTICE TO APPLICANT: If; after making this Certificate of APPLICANT 'l—
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W.
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS 100 6 (.9)0 7 C/
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ c
LICENSED CONTRACTORS DECLARATION Hood _ Fan Other_., CITY (•g �' Tel.No.
I hereby affirm that I am licensed under provisions of Chapter 9. Disp. — Room Air Cond. uCENSE OR G 6 f � Class. C—
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER O
Professions Code,and my license is in full force and effect. power Apparatus&Large Appliances DISTRICT NO.. PROCESSED BY
e� `� Size&Type HP,KW,KVA,or KVAR
License Number G L`6`'�,GZ Lic.Class G Up to 1 Incl. FINAL
�.L' fL?.,.tc,�.fid Over 1 to 10 Incl. DATE I� O
Contractor ri Date (/ VALIDATION
Over 10 to 50 Incl. FINAL V
❑ I am exempt under Sec. Over 50 to 100 Inc. FI W
B.&P.C.for this reason Over 100 N
Date:�G^?-,f—4i 0 i Services,Swbd.,MCC&Panelboards ® Z
0-200 Amp.Under 600 V
Signature �� c 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 1 Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits fl���T.s
for the following reason(Section 7031.5,Business and Professions -
Code): 1 307 115..51)
El 1,
Conduits&Conductors 1,as owner of the property,will do the work and the structure IITEM J
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). ® TOTAL -1 15 o Leo
CONSTRUCTION LENDING AGENCY CHECK 115.50.
1 hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec,3097, PERMIT FEE (Sub Total) %CHAWGE .011
Civ.C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE 131300-0001 10/24/90
Lender's Address 3492 1 AN 1 G 0-24
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
representatives of this County to enter upon the above-mentioned
property for inspection purposes: SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date