HomeMy Public PortalAbout9821 RICHMOND WAY_Electrical__ WORKERS'COMPENSATION DECLARATION -663 io/ai APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self insure, CE-806G
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
❑ GG��''
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
Certified copy is filed with the county building inspection � n
1 &2-Family,Sq.Ft. +191 $ — $ LOCALITY'rgM 12i- e (r1(
_ NEAREST
department. Multi-family Sq.Ft. CROSS ST. 60LOL&! � e-54
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light—Sw.— MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed If the work involved by the First 20 CITY Tel.No.
permit is for one hundred dollars($100)or less.) Total No. Additional
PLAN CHECK
I certify that in the performance of the work for which this permit 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
Additional
Q i �.,�,`L Total No. CITY � Tel.No.
Date V �K Applicant I-+g rI)ec Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMITAPPLICANT
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, d0C) 6CIe Z*G
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ CITY' j
yy)�(1Z ( '' Tel.No. S��f�&
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR
6316-1— Class.
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBBERER C L
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
,yrs
Size&Type HP,KW,KVA,or KVAR ��
License Number G G 96 Lic.Class L Up to 1 Incl. FINAL v
/� � Over 10 to 50 Incl.
1 to 10 Incl.
DATE
Contractor al C-)- --Date `d—Z-'-( VALIDATION 0
E] ncl. FINAL
I am exempt under Sec. Over 50 to 100 Inc. BY W
IL
BAP.C.for this reason Over 100
Services,Swbd.,MCC&Panelboards ® Z
Date: 0-200 Amp.Under 600 V
Signature 2.01 - 1000 Amp.Under 600 V
ElExemption
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 L
1 hereby affirm that I am exempt from the Contractor's License LawAdditional Sign Branch Circuits ; '? X
for the following reason(Section 7031.5,Business and Professions g (-) = =g
Code): — R
—-
Misc.Conduits&Conductors s Ij f 45 .I_
El I,as owner of the property,will do the work and the structure ITEMS
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ i
and Professions Code). ® TOTAL 1 -15 =50
CONSTRUCTION LENDING AGENCY i-3�GE� 115.J:
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.8097, PERFEE (Sub-Total) CHANGEGOCiv.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 110f,�0l-00III I01/24=./4(
Lender's Address ?
I certify that I have read this application and state that the above TOTAL FEE //n'y V =497 j AN 101.25
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