HomeMy Public PortalAbout9719 WINDSOR LN_Electrical__ t' •WORKERS'COMPENSATION DECLARATION 76A663 10/81
hereby affirm that I have a Certificate of consent to self CE-8066 APPLICATION FOR ELECTRICAL PERMIT 46-.2,3,0
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF'LOS ANGELES BUILDING AND SAFETY �.
or a certified copy thereof(Sec. 3800, Lab. C.) U
Policy No. 9501115 Company STWM 114M FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. & Pools EACH NO. FEE ADDRESS 9719 EDWSM IN.
19 Certified copy,is filed with the county building inspec- 1 &2-Family, Sq. Ft.- 1819 $ 038 — $ 69 12 LOCALITY'1 ,E CITY
tion department. Multi-family Sq. Ft. — NEAREST
Residential Swimming Pools -� CROSS ST.
Date 11x24=86 Applicant- EMysS 3TC. s OWNER OR oyj�W
FIRM NAME n � f'ATIr
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light. Sw._ I MAIL
COMPENSATION INSURANCE ADDRESS 2035 NEMS
This-section need not be com leted if the work Involved b First.20
( p Y Total No. Additional CITYNCNRMTTA 91016
Tel. No
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— f
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, after making this Certificate of APPLICANT s ''F31'ECTRT
Exemption, you should become subject to the Workers' Range_ Heater_D.W. .7 C
-Compensation provisions of the Labor Code, you must forth- Oven —Dryer _W.M. — ADDRESS 1-023 7AVE. ,
With comply with such provisions or this'permit shall be Top _ FAU —W.H.
deemed revoked. CITY Tel. Nol-597 -4741
LICENSED CONTRACTORS.DECLARATION � Hood _ Fan _Other_ — � ' _ ,597-4741
Disp. _ Room Air Cond. LICENSE OR' 259475 Class.0-1.0
I hereby affirm that I am licensed under provisions of Chapter 9 REG. LIMBER
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCESS
and Professions Code,and my license is in full force and effect. Power Apparatus 8 Large Appliances i°1 Q� O:
Size 8 Type HP, KW, KVA, or KVAR '' V
259475 C=10 FINAL p�
License Number Lic. Class Up to 1 Incl. DATE
s Over 1 to 10 Incl.
Contractor ` S ffi'�" Date 11-24-86 VALID ON
❑ Over 10 to 50 Incl. F
I,am exempt under Sec. Over 50 to 100 Inc. W W
B.&P.C. for this reason Over 1.00 Z
Date: Services, Swbd.,MCC&Panelboards
0 -200 Amp. Under 600 V W7
Signature 201 - 1000 Amp. Under 600 V
❑
�690:7A
Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V #•o. 0 0 0 0 '2
SINGLE FAMILY Temp. Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit I o o79.62 -
I hereby affirm that I am exempt from the Contractor's License Additional Sign Branch Circuits x
Law for the following reason (Section 7031.5, Business and
79.620
Professions Code): '
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors 4,2 3 $7
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 10 50
PERMIT ISSUING FEE
Lender's Address
I. certify that I hove 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) do d pro ty for' pectin purpos
SEE REVERSE FOR EXPLANATORY LANGUAGE
gnature Permitt a DatelL