HomeMy Public PortalAbout9718 WINDSOR LN_Electrical__ WORKERS'COMPENSATION DECLARATION 10/81
1 APPLICATION FOR ELECTRICAL PERMIT P.O
I herelyCE-806G that I have a certificate of consent to self CE-BO6G
• insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY a3(}
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. 55011,5❑. CoNew Residential Bldgs. &Pools Company—STM FOR APPLICANT TO PILL.IN JOB 971-
Certified copy is hereby furnished. EACH NO. FEE ADDRESS
Certified copy is filed with the county building inspec- 1 &2-Family,Sq. Ft. 1806 $ — 5 LOCALITY rIl�1PL Cl'Y
tion department. Multi-family Sq. Ft. — ' NEAREST
s Residential Swimming Pools ;� CROSS ST.
Date11-24-86 Applicant S EIEC.-IM. i 1 FIRM NAOR
ME OfAM DEVELCENMr
CERTIFICATE OF EXEMPTION.FROM WORKERS' Outlets: Rec Light. Sw._ ' MAIL 2035 '�
COMPENSATION INSURANCE ADDRESS
(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 �s 91016 Tel. No359-32.11
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�sS 'T�' �Mr IEW
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 IA973'rf'ET1�Fli'A1 AVE.
with comply with such provisions or this permit shall be 1 _ Fan _ _Top _ FAU —W.H: —
deemed revoked. Tel. No'
Hood OtherCITY (11M ;s 597-4741
LICENSED CONTRACTORS DECLARATION LICENSE OR
Disp. _ Room.Air Cond. — class
-C-10 .
(commencing with Section 7000)of Division 3 of the Business. Rower Apparatus&Large Appliances DISTRICT NO. PRO ED
and Professions Code,and my license.is in full force and effect. fQj
259475 C-10 Size 8 Type HP, KW, KVA, or KVAR' 6vof
License Number Lic: Class.. Up to 1 Incl. FINAL
I Over 1 to 10 Incl. DATE• V LIDATION 0
Contractor .TRRRY 8 hT]V---771Ydpte 11-74-86Over 10 to 50 Incl. I FIAj
W
❑ �1S9Q6A
I am exempt under Sec. Over 50 to 100 Inc.
B.&P.C. for this reason Over 100 # 0 0 0 0 0 2
Date: Services, Swbd., MCC&Panelboards
0 -200,Amp. Under 600 V ► o 0 7 9A 2
Signature 2.01 - 1000 Amp. Under 600 V - 79,126
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect. 4,2 3"8 7
SINGLE FAMILY Temp. Power Pole&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 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- 0
.Lender's Address
I certify that I have read this application and state that,the I TOTAL FEE 79.112
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-rQion d prop y for' spectio purpos s.
SEE REVERSE FOR EXPLANATORY LANGUAGE
lure o Permitte Dat t