HomeMy Public PortalAbout9810 WINDSOR LN_Electrical__ WORKERS'COMPENSATION DECLARATION 76A66310/81 APPLICATION FOR ELECTRICAL PERMIT
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I hereby affirm that I have a certificate of consent to self insure, CE-808o66
or a certificate df 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
ADDRESS y JUw
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE
❑ Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. /0� $ — $ LOCALITY ""r"M#41 C_ fry
department. Multi-family Sq.Ft. — NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME. ��+ G7
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rao_Light—Sw.— MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed If the work involved by the First 20 CITY Tel.No.
permit Is for one hundred dollars($100)or less.) Total No. Additional PLAN
I certify that in the performance of the work for which this permit APPLICANT CHECK .� v
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
Ip--2ct-�a G �f eaT'✓ct: Total No. Additional CITY Tel.No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PER
61J
Exemption,you should become subject to the Workers'Compensation Range_ Heater D.W.
provisions of the Labor Code,you must forthwith comply with such Oven — Dryer_ W.M._ ADDRESS too Q-m Z C
provisions or this permit shall be deemed revoked. Top _ FAU _ W.H. _
CITYrtfy ` Tel.No. 310
LICENSED CONTRACTORS DECLARATION ' Hood _ Fan _ Other_ /� •�
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE
MBER G 0 / Class.
(commencing with Section 7000)of Division 3 of the Business and
Professions Code,and my license is in full force and effect. DISTRICT NO. PROCE ED BY
Power Apparatus&Large Appliances �j Q
G Lite 0'76 7- G Size&Type HP,KW,KVA,or KVAR �el �b '- U
License Number .0'76 Lic.Class �y ! Up to 1 incl. FINAL 7 a
Contractor _� "C Date ^�Y� `a Over 1 to 10 Incl.. DATE ��1v- /1 VALIDATION
Over 10 to 50 Inc]. FINAL p J
❑ I am exempt under Sec. Over 50 to 100 Inc. BY G�"'W W W
BAP.C.for this reason Over 100 N
Services,Swbd.,MCC&Panelboards ® Z
Dat [ 0-200 Amp.Under 600 V
Signature �� 201 - 1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V
Exemption for R dgMaInt.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits °v A zU n
for the following reason(Section 7031.5,Business and Professions �
Code): '3itis°150
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
ITEMS,
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _ _
and Professions Code). ® TOTAL AL I :V5 m 543
CONSTRUCTION LENDING AGENCY CHECK 115.5i.",
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total) N�Ft °U-
0
Civ.C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE 0000-00111000-00111 10/2 9 i
�� — ' zr
Lender's Address 3487
°1 AM 10 C L�
1 certify that I have read this application and state that the above TOTAL FEE lIJ-
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 j
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date