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Home My Public Portal About9727 WINDSOR LN_Electrical__ WORKERS'COMPENSATION DECLARATION 7E 10/81 APPLICATION FOR ELECTRICAL PERMIT `+ I li'erisb; affirm that I have a certificdte of consent}to self •` 'Iin.S ra,or a;certlficate of-Workers'-Compensation Insurance„ %1r. COUNTY OF LOS ANGELES BUILDING AND SAFETY or q certified"copy thereof(Sec. 3800,Lab. C.) S'! f h, 55'©115 S 'E• •�ND Nf ,` FOR APPLICANT TO FILL IN JOB Policy No. Company & WINDSM IN. ' Certified copy is hereby furnished. ` .r-. 1 New Residential Bldgs. &Pools EACH NO. FEE ADDRESS rr—r Certified copy is filed with`fhe county building inspec- i1( 1 &2-Family, Sq. Ft.2026 $.038 —1$-76.98 LOCALITY TEMpM. CM r NEAREST tion department. " I Multi-family Sq. Ft. — CROSS ST. r. �. • a ' esidential Swimming Pools 11-25-86 I+cant ` Y S T•T.�Y�172T-Co, OWNER OR nPMF�TP I:! Date App' I j� FIRM NAME QTIm n� CERTIFICATE OF EXEMPTION FROM WORKERS' .1 EXEMPTION Rec Light Sw:_ ; MAIL 2035 'COMPENS'ATION INSURANCE '1 First 20 ti (This section need not be completed if the work involved by J/ Total No. Additional CITY Mrlam Tel. NO.359-3211 -the permit is for one hundred dollars($100)or less.) �, PLAN CHECK 1 certify,161cit in the performance of the work.for Which this l APPLICANT Ipermit is issued,I shall not employ any person in any manner Li sting Fixtures First 20 ! ADDRESS so A to become subiect to the Workers'Compensation Laws. Additional 1 �4 j otal No. CITY Tel. No. Date Applicant �' v Pp Fixi d Appliances Not Over 1 HP PERMIT NOTICE TO APPLICANT: If, after making this�C&!i icgate of APPLICANT J 'S STC• - 1�(Vl an e_ Heater_D.W. .E.zemption, you should become subject to the+�j: orkers' R• g + C�impensation•provisions of the Labor Code, you m.�'st forth- /•ven _Dryer _W.M. ADDRESS 11 49-3'T,-Cil 7>\TM;!AVE. comply with -such provisions or this'perp'kshall be ` op _ FAU' W.H. — ` % ! de med revoked. ! CITY ;i• )7, tel. IVci. � +' /�r Hood _ Fan _Other_ � 11 + i LICENSED CONTRACTORS DECLA?ae ION LICENSE OR �, Ti� Disp. _ Room Air Cond. Classhe eby'affirm that I am licensed under proo Chapter 9REG.NUMBER 2rj c �nencing with Section 7000)of I ivisiQQ t e Business power Appdratus&Large AppliancesI+ DISTRICT NO. PRO Dai Professions Code,and my license.is rffuort.and effect. i `` +l�r r Size&Type HP, KW, KVA, or KVAR � L+ce6e Number. 25LD2T7� Y Lic.tClass U' t fY . :i ;,.} p: 0 1 Incl. ' + FINAL , . w Over 1 to 10 Incl. DATE O 1 e + V' LIDATION .J� 'p� S ECr ate 1.1' V 77 Over 10 to 60 Incl. um exempt under SSC +'' Over 50 to 100 Inc. BY A Q bv for,fhis r)an'r. { �� , i Over 100 �f� S erivices, Swbd.,MCC&Pon' lboords n .11. t .Date +- v 0 -200 Amp:.Under 600 V S ti S%glure ` 1'. + `� ` 201 - 1000 Amp. Under 600 V ! st + Over 1000 Amp. or Over 600 V I z 6 9 Q 2 A Exe ptic)n for Reg`Mai nt.,Elect. ' #,0 0 0 0.0 2 + SINGLE FAMILY" y , Temp. Power Pole&Appurtenances ' •HOME OWNER-BUILDER DECLARATION � � Sign with One Branch Circuit I hereby offi}m that:I am exe.m}�t frorn the Coptractor's License 8 7 4•$S y , Law forlthe following reason (Section 7031.5, Business`�nd Additional Sign Branch Circuits o 0 o a Professic.is Cocle) 1 ' t ❑ !;as owner of th, `� 5 \ Misc. Conduits&Conductors t, [( 2;3,+ $`] , �pr�erty,'�will do the work and.the a ;! structure is not in'ended or,offered for sale (Sectidn Other(see Complete Fee Schedule)_ , 7044, Business and 'rofessions.Code). t CONSTRI}.CTION LENDING AGENCY { .1 hereby affirm that ther tts oconstructi'on lending agency for I -0 ' the performance of theNvork For which'this permit is issued PERMIT'FEE (Sub-Total) ' Sec. 3097,Civ. C.). ' .11 -' PLAN CHECKING FEE o t L'ender's Name PERMIT ISSUING FEE 10.50 / d 'Lender's Address 1 yertify that 1,have read this plicc�on and!s��a,te that the TOTAL FEE 87• !'.abtOve information is correct. I a ee to•`limply Wit}�tall County {} n ° r- e =J + ordinances and,State laws reg ting L11, trical wi�'ng, and herebyou tliorize representatives this�int. to enter upon , �'t7 �. Y �� M. r,co Z:: th bov!_ ntio d pro rty for 3pectia,}purposes;. { , ' .,t' ?;'•,J�- SEE REVERSE FOR EXPLANATORY LANGUAGE 4 atu o ermitt D lto