HomeMy Public PortalAbout11201 WINDSOR LN_Electrical__ Y WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I �ereby affirm that I have b certificate of consent to self CE-86G 0 ���
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND.SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.) LLLIII
Polity
cy No. 550115 CompanySwIM 11= FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. NEACH NO. FEE ADDRESS 9 LANE
ew Residential Bldgs. 8 Pools
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. 1690 $.038 — $ 64L2jLOCALITY 7EMPM 'QW
tion department. Multi-family Sq. Ft. — NEAREST
Date 11-24-86s Residential Swimming Pools CROSS ST.
i4pplicantY S EfyF���T11TL OWNER OR 01HIMDEVIMCEPIMT
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Li ht Sw._ MAIL
COMPENSATION INSURANCE g ` ADDRESS 2035 N UM
(This section need not be completed if the work Involved by First 20
the permit is for one hundred dollars($100)or less.)
Total No. Additional CITYMMIUM 91016 Tel. No.359-3211•
,
• I certify that in the performance of the work for which this PLAN CHECK
_ APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20' ADDRESS
Additional
Total No.
CITY Tel. No.
Date- Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of
Exemption, you should become subject to the Workers' Range_ Heater—D.W. — APPLICANT J$ s$ EEBCPRTC 1W
Compensation provisions of the Labor Code, you must forth- Oven _Dryer _W.M._ __ ADDRESS
with comply with such provisions or this'permit shall be Top _ FAU —W.H:
deemed revoked. Hood _ Fan _Other_ CITY..- _ � ) Tel. Noll
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. _ Room Air Cond. — 259475 Class.0-10
I hereby affirm that I am licensed under provisions of Chapter 9 REG. NUMBER
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PRO E /BY
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances i r/ r
259475 Size&Type HP, KW, KVA, or WAR T �!/1 p�
License Number- Lic: ClassC-10 Up to 1 Incl. FINAL 0.
DATE
s Over 1 to 10 Incl.
Contractor aTl -S �+1 = Date 11-24— 6 !/ LIDATION
ElOver 10 to 50 Incl. FIN
I am exempt under Sec. Over 50 to 100 Inc. BY W,
B.&P.C..for this reason Over 100 Z
Date: Services,Swbd., MCC&Ponelboards ® _6 9 Q1 A —
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V # o•0 0 0 0.2
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp, or Over 600 V .1 o•o 7 4.,7.2
SINGLE FAMILY Temp. Power Pole&Appurtenances o o"o 74,7253
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
1 hereby affirm that I am exempt from the Contractor's License Q a.2 3=
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits $7
Professions Code):
j ❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_ ►
7044, Business and Professions Code.).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
Lender's Address
PERMIT ISSUING FEE 105 '
_
certify that I have read this application and state that the TOTAL FEE 74.7
above information is correct. I agree to comply with all County
otdinances and State laws-regulating Electrical wiring, and"
hereby authorize representatives of this County to enter upon'
th bove- tioned pro y for' spection urposes. I
SEE REVERSE FOR EXPLANATORY LANGUAGE 1
ign1afur Permit a Date ti•;•/
` i •i /