HomeMy Public PortalAbout9715 WINDSOR LN_Electrical__ WORKERS'COMPENSATION DECLARATION' CE-806 10/81 APPLICATION F R ELECTRICAL
L PERMI �
I hereby affirm that I have a certificate of consent to self CE-8066 IF. LK ��ssB� ilt II l7
insure, or 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 SSPE FM FOR APPLICANT TO FILL IN JOB 9715 WnESO t LN.
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. 1819 $.038 — $ 69 12 LOCALITY TEMPI$
tion department. Multi-family Sq. Ft. — NEAREST
Date 11-24-86 Applicant �sS E'BC's1W. Residential Swimming Pools CROSS ST.
OWNER OR
FIRM NAME DnPP�a1TP
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ 3876 DAG 110.
COMPENSATION INSURANCE DRESS
(This section need not be completed if the work involved by First 20 ADDRESS
Total No. Additional CITY �. 91706 Tel. No359-3211
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
Date Applicant CITY Tel. No.
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT '�■S ELB=C• 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 ,149ZI TELE.PEBOM AVE.
with comply with such provisions or this permit shall be _
.deemed revoked. Hood _ Fan _Other_ CITY C HED Tel. No-597-474.1
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. _ Room Air Cond.
T hereby affirm that I am licensed under provisions of Chapter 9 REG.NUMBER 259475 Clas .—
10
(commencing with Section 7000)of Division 3 of the Business power Apparatus 8 Large Appliances DISTRICT NO. �� PROLE a
and Professions Code,and my license is in full force and effect.
Size&Type HP, KW, KVA, or WAR
License Number 259475 Lic. Class C-40 Up to 1 Incl. FINAL Lt:
s Over 1 to 10 Incl. DATE p
Y S TtiT.T�' 02 1 JDATION
Contractor ate 1-24-86 Over 10 to 50 Incl. FINL)
❑ I am exempt under Sec. Over 50 to 100 Inc. W'B a•
B.&P.C. for this reason Over 100 ;2 6 4 Q 8 A
Date: Services,Swbd., MCC&Panelboards # 0 0 0 0 0 2
0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600 V 1 - 79,62
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V o 0 0 7 9.6 2 v
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit 04,23-87
1 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 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 ,
PERMIT ISSUING FEE. 10 50
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 79.62
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 ove- nfi ed pr erty fo inspecti purpose .
SEE REVERSE FOR EXPLANATORY. LANGUAGE
g ature of Perm' ee Dat