HomeMy Public PortalAbout9807 RICHMOND WAY_Electrical__ WORKERS'COMPENSATION DECLARATION 7BA683 CE-80806G 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, ,
or a certificate of Workers' Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800.Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB �D
Certified copy is hereby furnished. New Residential Bldgs.&Pool7 `�`� DX
❑ EACH NO. FEE ADDRESS'
Pools
❑ IJD
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. ' 9015 $ _ $ i7� 0 LOCALITYT - ,JL G: G (-r y
department. Multi-family Sq.Ft. NEAREST Wee
_��.r� r 4,�
Residential Swimming Pools CROSS ST. - /r, (j(/' P )
Date Applicant OWNER OR
NAME he
FIRM •e G a
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_ MAIL n
—
COMPENSATION INSURANCE Sw. ADDRESS 0� r7 60-0 4Y4
completed if the work involved b
P y
(This section need not be com the First 20 r, ilqk
Total No. Additional CITY ✓✓t(9�(� G I�' Tel.No. rS 3✓f
permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this permit APPLICANT 2'jar
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
Additional
!/ + �� Total No. CITY Tel.No.
DateF{�'�Y Applicant Gi-f� Its Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT
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 Dr) 0o I-V 6
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ CITY h e_/ Tel.No. -W
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR 0 1Z Class C
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
Size&Type HP,KW,KVA,or KVAR 11:9,
License Number C, I/&c)176 Z Lic.Class C_ Up to 1.Incl. FINAL U
G• f �C� Date �� I Over 1 to 10 Incl. DATE 0 14 1 VALIDATION
Contractor Over 10 to 50 Incl.
FINAL
❑ I am exempt under-Sec. Over 50 to 100 Inc. BY
BAP.C.for this reason Over 100 Q
Services,Swbd.,MCC&Panelboards ® Z
D te: 0 200 Amp.Under 600 V Is
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 i
1 hereby affirm that I am exempt from the Contractor's License Lawr•" s
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits ) '+r)='e•
Code): 33137 115.50
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors 1 ITEM -
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _
and Professions Code). TOTAL 115 m 50
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) /}A ISO CHANGE .00,
Civ.C.).
PLAN CHECKING FEE
Lender's Name 0000-00011 10/24/90
PERMIT ISSUING FEE l
Lender's Address -3493 1 Ate 10-q-24
I 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