HomeMy Public PortalAbout9813 RICHMOND WAY_Electrical__ WORKERS'COMPENSATION DECLARATION r CE 8o6G 1057 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
❑ Certified co is hereby furnished. EACH. NO. FEE ADDRESS j
PY New Residential Bldgs.&Pools
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. , ll.� $ -- $ LOCALITY 14,);- L-
ffy
department. Multi-family Sq.Ft. — NEAREST �pp
CROSS
Residential Swimming Pools ST�c7�pCtoi� �J� rf�
Date Applicant OWNER OR I ,�
. FIRM NAME�•��'��. 1�
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec Light Sw. MAIL
— _ _
COMPENSATION INSURANCE. � ADDRESS1.d &14 2—W
(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 �f�G / Tel.No.Z �.
I certifythat in the performance of the work for which this permit PLAN CHECK
P P APPLICANT
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
l� r
Total No. Additional CITY. Tel.No.
Date lg2_ze/-10 Applicant 6f' '� �
Fixed Appliances Not Over 1 HP PERM
APPLICANT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ ANT (� ��
provisions of the Labor Code,you must forthwith comply with such Oven Dryer_ W.M._ I ADDRESS (�•-� ZfP
provisions or this permit shall be deemed revoked. Top FAU _ W.H.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _ Other_ CITY G4 Tel.No..
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. LICENSE OR
(commencing with Section 7000)of Division 3 of the Business and ' REG.NUMBER e qcft 6-1— Cis L
Professions Code„and my license is in full force and.effect. Power Apparatus&Large Appliances DISTRICT NO. 5OCESSEQ BY
/ r Size&Type HP,KW,KVA,or KVAR --
Q� �'
License Number j, ®``�� Lic.Class G Up to 1 Incl. •FINAL `•�
Contractor�✓'�`� �� t`� Date /C�'9ZK��� Over 1 to 10lncl. DATE VALIDATION -0
Over 10 to 50 Incl. FINAL C~.3
❑ I am exempt under Sec. Over 50.to 100 Inc. BY W
B&P.C.for this reason. Over 100 13-
te: b'"�����; Services,Swbd.,MCC&Panelboards
0 200 Amp.Under 600 V
Signature 201 - 1000 Amp:Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Ele
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
.I hereby affirm that I am.exempt from the Contractor's License Law ACCT F•
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits "
Code): +3307
Misc.Conduits&Conductors t r�
El 1,as owner of the property,will do the work and the structure ' Other(See.Complete Fee Schedule) _ t ITE+tS
is not intended or offered for sale (Section 7,044, Business '
and Professions Code). ® TOTAL 1-95 a 50
CONSTRUCTION LENDING AGENCY CHECK #IM0
I hereby affirm that there is a construction lending agency for the ,
performance of the work for which this permit is issued(Sec.3097, I PERMIT FEE (,Sub Total) CHANGE .-00
Civ.C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE �� _ 0000-0001 10/24/90
I �
Lender's Address i 3495 1 AN10 a 25
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
' � 1
Signature of.Permittee Date