HomeMy Public PortalAbout9712 WINDSOR LN_Electrical__ WORKERS'COMPENSATION DECLARATION 7E-806 10/81 APFF" ICATION 'FOR E1 ECTRI A PERM17 V.U.
.l,Kereby aFfirm that I have a certificate of consent to self CE-8066 M7� [� tl ELECTRICAL iL mutt IJ
• insure,"o�a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a Certified copy thereof (Sec. 3800, Lab. C.)
Policy No. 550115 Company STM FM
FOR APPLICANT TO FILL IN JOB
Certified co is hereby furnished. ADDRESS copy
4 -
pY y , New Residential Bldgs. 8 Pools EACH NO. FEE
Certified copy is filed with the county building inspec- 1 8 2-Family, Sq. Ft. 1806 $ -038 — $ 68 62 LOCALITY IJENEW CITY
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools CROSS ST.
Date —74—Rfi -Applicant T{[J3C 1W OWNER OR
pP ���"'- FIRM NAMECIMM j l71-PPI1F9�TP
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
Outlets: Rec Light Sw._ 2035F.
COMPENSATION INSURANCE First 20 ADDRESS
(This section need not be completed if the work involved by Total No. Additional CITY 1dA 91016 Tel. No,359-3211
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this PLAN CHECK
permit is issued, I shall not employ any person in any manner APPLICANT
so as to become subject to the Workers'Compensation Laws. I Lighting Fixtures First 20 ADDRESS
Total No. Additional
Date Applicant CITY Tel. No.
Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT aT��ss FT.FY'I42T
Exemption, you should become subject to the Workers' Range_ Heater—D.W. APPLICANT C.s IW-
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. — 44923— .
deemed revoked. Hood _ Fan _Other_ CITY: j Tel. No-:597-4744
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. _ Room Air Cond. Cla 25.9475 sic—1 Q
(commencing with Section 7000) of Division 3 of the Business power Apparatus 8 Large Appliances DISTRICT NO. PRO D BY n_
and Professions Code,and my license is in full force and effect:
259475 C 10 Size 8 Type HP, KW, KVA, or KVAR 54� U
License Number Lic. Class Up to 1 Incl. FINAL
Over 1 to 10 Incl. DATE
Contractor ` s ffi'� Date 11-24-86 VA I
t
❑ Over 10 to 50 Incl. FIN U a
W
I am exempt under Sec. Over 50 to 100 Inc. B # 0 0 0 0 - 2 z
n
Over 100 .
B.BP.C. for this reason
% ,
Services, Swbd., MCC 8 Panelboards !1 79,12
Date:
� 0 -200 Amp. Under 600 V =
Signature 201 - 1000 Arrip. Under 600 V o o o '7 9.J 2.0
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V U 4,2 3-8 7
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
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
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the M;sc. Conduits 8 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 1Q. 50 ,
Lender's Address PERMIT ISSUING FEE
1 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
Aebyorv_e
uthorize representatives of this County to enter upon
d prop for i pection urpose�.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Dat