HomeMy Public PortalAbout9707 WINDSOR LN_Electrical__ { .O e�. WORKERS'COMPENSATION DECLARATION 76A663 10/81Wi l y� y� w' to ® 'V
I her2by affirm that I have a certificate of consent to self CE-8066 P UCA If ION FOR ELECTRICAL PERMI'
` insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY 6.286
or a certified copy thereof(Sec. 3800, Lab. C.) _
Policy No.550115 Company AMM ]AND FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. EACH NO. FEE ADDRESS
copy y New Residential Bld'gs.•�8�,P�QI
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. 1��� $ _ $ 68.62 LOCALITY TENEM
tion department. Multi-family Sq. Ft. NEAREST
Residential Swimming Pools �1 I \ CROSS ST.
DateM—fly Qo_Applicant s :W. ` ` OWNER OR � C ff
/ a ` i ;1 FIRM NAME a1�LS
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light- Sw._ ,. 1 MAIL
COMPENSATION INSURANCE -. First 20 ADDRESS 2111135 WRT1,13
(This section need not be completed if the work involved by Total No. Additional CITY jll Tel. No. 359-3211
the permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this 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
Total No. Additional
CITY Tel. No.
Date- Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT ' S F'f.F�'1�TC/ INC-
Exemption, you should become subject to the Workers' Range_ Heater_D.W.
Compensation provisions of the Labor Code, yob must forth- Oven —Dryer —W.M.— ADDRESS d
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY ( 141. NoTo-4-69�_.'] •1
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other— _
LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. REG.NUMBER . A S _ Class.
(commencing with Section 7000)of Division 3 of the Business power Apparatus&Large Appliances DISTRICT NO PRO ED Y
0�.
and Professions Code,and m License is in full force and effect. d -
Y Size&Type HP, KW, KVA, or KVAR' OL
�U
259475 C 10 Up to 1 Incl. , FINAL
License Number Lic. Class
Over 1 to 10 Incl. DATE ,� ALIDATION 0
Contractor Date Over 10 to 50 Incl. F4 IfIN LL)
❑ I am exempt under Sec. Over 50 to 100 Inc. B LL:
B.&P.C. for this reason Over 100 Z
Services, Swbd., MCC&Panelboards
Date: 0 -200 Amp. Under 600 V �
Signature 201 - 1000 Amp. Under 600 V 96 9 0.4 A
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. # o o 0 o,o 2
SINGLE FAMILY Temp. Power Pole&Appurtenanceso o79. 12
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit =
1 hereby affirm that I am exempt from the Contractor's License o o o 7 Cl 1 2 5
Low for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits
Professions Code): 04,23-87
❑ 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) 68 62
(Sec. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name 1Q 50
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that the TOTAL FEE 79.12
above 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 bove-{mentioned prop ty for i pection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
XiArtaI
lure o ermifte Date I