HomeMy Public PortalAbout9708 WINDSOR LN_Electrical__ +' WORKERS'COMPENSATION DECLARATION
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t•hereby affirm that I have a certificate of consent to self CE-806G APP CAION FOR ELECTRICAL
ECTRICAL PERIT �D
L, insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY ;? I�
or a certified copy thereof(Sec. 3800, Lab. C.) O�/J u
Policy No. 550115 Company S'IZM FM FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. 8 Pools
EACH NO. FEE ADDRESS 970 WINDSOR LANE
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. 1949 $ _ $ LOCALITY
11111FIGMIR Mw
Y� tion department. Multi-family Sq. Ft. �— NEAREST
CROSS ST.
Residential Swimming Pools
Date 12-1—$6 Applicant JF92Ryr� � Tf 9 , OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec. Light Sw._
COMPENSATION INSURANCE MAIL
2035 1�TLE
(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 CITY miggaim Tel. No.359-321
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
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT JEEWVS F.f.1NY'MC IW.
Exemption, you should become subject to the Workers' Range_ Heater_D.W.
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:— 14923'M
deemed revoked. CITY:• �=-� Tel. Nd7l F,_597-47 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.NUMBER259475 Class. C 10
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROC D Y >-.
and Professions Code,and my license is in full force and effect. Power&Type
Hs 8 Large Appliances L].
Size 8 Type HP, KW, KVA, or KVAR, • i � V
Licepse Number 259475 Lic. Class C-10 Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE E V (DATION
Contractor e _ Date Over 10 to 50 Incl. FIN V
❑ W*
I am exempt under Sec. Over 50 to 100 Inc. B 0.:
B.&P.C. for this reason Over 100 �
Date: Services, Swbd'., MCC&Ponelboards
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V 2 6 9 Q 3 A
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V # 0 0 0.0 0 2
SINGLE FAMILY Temp. Power Pole&Appurtenances ) o o $11,2 9
HOME OWNER-BUILDER.DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License additional Sign Branch Circuits o 0 0 $IL 2 95C
Low for the following reason (Section 7031.5, Business and
Professions Code): &23 =$7
0
❑ 1, as owner of the property, will do the work and the M,sc. 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
PERMIT ISSUING FEE 10,50
Lender's Address
I certify that I have read this application and state that the LTOTAL FEE $4 29
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
Aebove-m ntl ed pro rty for i ection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
r Permitt Date ,