HomeMy Public PortalAbout9723 WINDSOR LN_Electrical__ WOR COMPENSATION DECLARATION �, 764663 10/81
Whereby Affirm that 1 have a .certificate of consent to self CE-&6G APPLICATION. FOR ELECTRICAL PERMIT ®^^,
4,insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY p`a®
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy N6.550115 Company STME MM FOR APPLICANT TO FILL IN JOB
Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS 97 TA»'
.Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft. 1690 $ n38 — $ LOCALITY R QW
tion department. Multi-family Sq. Ft. 1 NEAREST'
11-24-86 Applicant: JERRy�S � � Residential SwimmingPools CROSS S.T.
Date g�" OWNER OR.
- ; FIRM NAMEQIBW
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Li. ht Sw._ MAIL
COMPENSATION INSURANCE g ADDRESS 12035 M.
(This section need not be completed if the work Involved by First 20
the permit is for one hundred dollars($100)or less.) Total No. Additional CITY A Tel. N0.359-3211
I certify that.in the performance of the work for which this PLAN CHECK
permit is issued,I shall.not employ an APPLICANT
p p y y person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional -
Date Applicant CITY Tel. No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
APPLICANT aTERW'$ FFMC1 C 1W�
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
with comply with such provisions or this permit shall be Top' _ FAU —W.H. — 1�1923 �ri�'
deemed revoked. Hood _ Fan _Other_ CITY.- CEM Tel- N-697-4741LICENSED CONTRACTORS DECLARATION
I hereby affirm that I amLICENSE OR.licensed under provisions of Chapter 9 Disp. _ Room Air Cond. REG..NUMBER 259475 Class.C-10
(commencing with Section 7000)of Division 3 of the Business power Apparatus'8 Large Appliances DISTRICT NO. PRO D tF , d
and Professions Code,and my license is in full force and effect:
9t
Size&Type HP, KW, KVA, or KVAR (�
License Number 259475 _ Lic. Class C'�1Q. Up to 1 Incl. FINAL.
Over 1 to 10 Incl. DATE ✓ Qi (DATION
Contractor C 1Rf1 Date 11 a4 Over 10 to 50 Incl. FINAL W
❑ I am exempt under Sec. Over 50 to 100 Inc. BY p:
IB.'BP.C. for this reason Over 100 Z
Date: Services, Swbd., MCC 8 Ponelboards
0 -200 Amp. Under 600.V
Signature 201 - 1000 Amp. Under 600 V {
}I Over 1000 Amp, or Over 600 V
❑ Exemption for Reg. Maint. Elect. b 9 Q 0'A
r SINGLE.FAMILY Temp. Power Pole&Appurtenances
1. ti HOME OWNER:BUILDER DECLARATION 0.0 0 0 0'2
Sign with.One Branch Circuit
r,1 I hereby affirm that 1 am exempt.from.the Contractor's License
Law for the following reason (Section 7031.5, Business and Additional Sign.Branch Circuits
•Professions Code):'• 1. -:.a 7 4,7 2
I, as owner of the property, will do the work and the
Misc.
Conduits 8 Conductors
structure is not intended or offered for sale (Section Other•(See Complete Fee Schedule)_ , 0,0'o 7 4.7 2 5
7044, Business and Professions Code). 4,'2 38 7
j { 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)
(Sep. 3097,Civ. C.).. 1�
1 PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE 10.5
Lender's Address
I certify that I have.read this application and state that the TOTAL FEE 74.7
above information is correct.I agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby 0uftrize representatives of this County to enter upon
*tbov�*e- pinspection purpos1 SEE REVERSE FOR EXPLANATORY LANGUAGE Dat