HomeMy Public PortalAbout9813 WINDSOR LN_Electrical__ WORKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION FOR ELECTRICAL PERMIT
I hereby lffirrr! that I have a certificate of consent to self insure, CE-806G
or a certificate 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
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&Pools�� $EACH NO. $ FEE
LOCALITY AL e- r
E] Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft. —
department. Multi-family Sq.Ft. NEAREST
CROSS ST �v cd �s�-
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME V
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light—Sw.— MAIL
COMPENSATION INSURANCE ADDRESS
(This section need not be completed If the work Involved by the First 20
ao. Additional CITY Tel.No.
Total N
permit is for one hundred dollars($100)or less.) PLAN CHECK
I certify that in the performance of the work for which this permit APPLICANT
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
C44� ' !�� / ``� Additional
Date �V �- 6v 4� C:�y Total No. CITY Tel.No.
Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMITAPPLICANT
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 P(J `'W
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ CITYr1SW�t �+ Tel.No.
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE REG.NUMBER �6Z Cisss C
(commencing with Section 7000)of Division 3 of the Business and
Professions Code,and my license is in full force and effect. DISTRICT NO. PROC SS D BY
Power Apparatus&Large Appliances
Size&Type HP,KW,KVA,or KVAR 4
License Number L 6094 L Lic.Class �" Up to 1 Incl. FINAL /
✓dOver 1 to 10 Incl. DATE .�` ��j VALIDATION 0
Contractors It" l d Date /(7 rZ� 9y O
E] Over 10 to 50 Incl. FINAL ,/ ~
I am exempt under Sec. Over 50 to 100 Inc. BY OW.
B.&P.C.for this reason Over 100 N
j V -Zr( Services,Swbd.,MCC&Panelboards ® Z
D-a�te:.D 0-200 Amp.Under 600 V
Signature -ate 201 - 1000 Amp.Under 600 V
❑ 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
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits
Code):
Misc.Conduits&Conductors
I,as owner of the property,will do the work and the structure i 1
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule)
and Professions Code). ® is;AL 2L 15. • of l
CONSTRUCTION LENDING AGENCY
hereby affirm that there is a construction lending agency for the
erformance of the work for which this permit is issued(Sec.3097, PERMIT FEE1"}iiii�= a
iv.C.). (Sub-Total)
PLAN CHECKING FEE
-ender's Name
PERMIT ISSUING FEE
Lender's AddressTOTAL FEE Al l,) r+
I certify that I have read this application and state that the above
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