HomeMy Public PortalAbout9802 WINDSOR LN_Electrical__ WORKERS'COMPENSATION DECLARATION 78-883 10/81
CE-808G APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certifiead of consent to self insure,
or a ce0ficate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.) fl
Policy No. Company FOR APPLICANT TO FILL IN JOB 002
Certified co is hereby furnished. EACH NO. FEE ADDRESS �>,� //(I/�sp,� ✓ftllrC
PY Y New Residential Bldgs.&Pools
1 & 2-Family,S Ft. LOCALITY Pg„Iy C
Certified copy is filed with the county building inspection y q• O $ — $ �" ✓�
department. Multi-family Sq.Ft. — NEAREST
CROSS ST. �• °i�./f�'�
Date Applieant
Residential Swimming Pools OWNER OR �y
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' MAIL
COMPENSATION INSURANCE Outlets:Rec—Light—Sw.— ADDRESS
(This section need not be completed if the work involved by the First 20
permit Is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.No.
PLAN CHECK ��� q
I certify that in the performance of the work for which this permit APPLICANTyj
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
Date 0-?-L( Additional Applicanty�G` �- Total No. CITY Tel.No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W. _ APPLICANT
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS f o 130,.0 7,T i-
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _ CITY �/�j�J/,,,� Tel.N �!/C�
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ IF
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class.
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER 9
Professions Code,and my license is in full force and effect. .DISTRICT NOPROCE BY
Power Apparatus&Large Appliances �. !�
�/�oW n Size&Type HP,KW,KVA,or KVAR ofTl�:
License Number '`�"� [6 Lic.Class (- Up to 1 Incl. FINAL
-�' �� `Rt ���� Over 1 to 10 Incl. DATE ���L-�� VALIDATION 10
CIAJ
Contractor a -e-4 Data -WOver10 to 50 Incl. I-
FINAL V
I am exempt under Sec. Over 50 to 100 Inc. BY %/ W
B.&P.C.for this reason Over 100 N
te: Services,Swbd.,MCC&Panelboards ® Z
0-200 Amp.Under 600 V
Signature_ 201 - 1000 Amp.Under 600 V
El
Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances ,-
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit - a
I hereby affirm that I am exempt from the Contractor's License Law y�.• ,,y
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits
Code):
Misc.Conduits&Conductors _ -
I,as owner of tho property,will do the work and the structure
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). ® TUI 115 FE.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the V" V r., i - _
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) ��r'"� :.!'�fCNEEE -'-
Civ.C.).
PLAN CHECKING FEE
Lender's Name / I'I:CR-? 1210 ss_PERMIT ISSUING ISSUING FEE - -
Lender's Address 4-;q4t
I certify that I have read this application and state that the above TOTAL FEE 5-0
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 above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date