HomeMy Public PortalAbout9722 WINDSOR LN_Electrical__ v.
WORKERS'COMPENSATION DECLARATION CE-806 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to self CE-806G
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUI DING AND SAFETY
or a certified copy thereof(Sec. 3800, Lab. C.)
550115
Policy No. Company STAM FUM FOR APPLICANT TO FILL IN JOB 9618 LN.Certified copy is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE
ADDRESS
Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. 1630 $L038 = S 611,94 LOCALITY TEMKE CTry
1
tion department. Multi-family Sq. Ft. NEARESTCROSS ST.
Date 11-24-86 Applicant�sS FT.F7(�IW2TC• _ Residential Swimming Pools OWNER OR '
FIRM NAME ONIM 1
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ I MAIL
COMPENSATION INSURANCE ADDRESS _3,q7fi pnNNnrW. MI
(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 ]I,I Tel. N6359-3211 I
I certify that in the performance of the work for which this PLAN CHECK
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 N.o. Additional
CITY Tel. No. 1
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT amass T�fFT*1'RT
Exemption, you should become subject to the Workers' Range_ Heater_D.W. APPLICANT Ci IWC
Compensation provisions of the Labor Code, you must forth- Oven —Dryer —W.M. ADDRESS 14yd3 r�`IR�AVE
with comply with such provisions or this permit shall be Top _ FAU —W.H. — _
deemed revoked. CITY' CH Tel. IV 591-4T41
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_
Disp. Room Air Cond. LICENSE OR
1 hereby affirm that I am licensed under provisions of Chapter 9 REG.NUMBER 259475 Class C 10 a
(commencing with Section 7000)of Division 3 of the Business power Apparatus 8 Large Appliances DISTRICT NO. PR ED BY
and Professions Code,and my license is in full force and effect. �` �) U
259475 Size&Type HP, KW, KVA, or KVAR 51,
License Number Lic. Class C 10 Up to 1 Incl. FINAL 1%
V Over 1 to 10 Incl. DATE ✓ VA ATION H
Contractors S Er Date 11-24-86
❑ Over 10 to 50 Incl. FINW
I am exempt under Sec. Over 50 to 100 Inc. BY q 6 91. A
BAP.C. for this reason Over 100 Z
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 0 0 7 2 4 4
❑ Over 1000 Amp, or Over 600 V 0 0 o 7 2 IL fl,.u
Exemption for Reg. Maint. Elect.
SINGLE FAMILY Temp. Power Pole 8 Appurtenances 0 IL 2 3—8 7 f
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 I
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 72.44
above information is correct. I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
A
authorW
f this County to enter upon
inspectio purpos . SEE REVERSE FOR EXPLANATORY LANGUAGE r o PD �1