HomeMy Public PortalAbout9816 WINDSOR LN_Electrical__ WORKERS'COMPENSATION DECLARATION - ,D/fl, APPLICATION FOR ELECTRICAL PERMIT
I hrgeb'y, affirm that I have a certificate of consent to self insure, C CE-Boa80B t
ora certificate of Workers' Compensation Insurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800.Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
ADDRESS ��p
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools $ LOCALITY 1 n
EACH NO. FEE
❑ 1 &2-Family,Sq.Ft. s 0� — $ 't L �(�
Certified copy is filed with the county building inspection NEAREST
department. Multi-family Sq.Ft. CROSS OWNER— l�SQ1 .fig i"
Residential Swimming Pools O
Date Applicant OR �.
FIRM NAME �O
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light—Sw.— MAIL
COMPENSATION INSURANCE ADDRESS
This section need not be completed if the work involved First 20
( b p Y the CITY Tel.No.
permit Is for one hundred dollars($100)or less.) Total No. Additional
PLAN CHECK
I certify that in the.performance of the work for which this permit
APPLICANT Q
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
Additional
Date i o 7-Q—9 'Applicant ''t—* 0��JTotal No. CITY Tel.No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT / rJ9 ri
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 p�j A—
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. i
CITY yj�j(! G� Tel.No. `tQ
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
I hereby affirm that I am licensed under provisions of Chapter 8Disp. — Room Air Cond. LICENSE OR �—
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER G w6 1 Class.
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. {� PROCESSED BY
G e of F1 Size&Type HP,KW,KVA,or KVAR �0O , �1J� Q
License Number Q Lic.Class L Up to 1 Incl. FINAL p 8
p DATE �/�// VALIDATION I%
I C , yam L �i ,g Over 1 to 10 Incl. O
Contractor (ji Date Over 10 to 50 Incl.
FINAL _/❑ P/ V I am exempt under Sec. Over 50 to 100 Inc. BY o"G W
B.&P.C.for this reason Over 100 N
O L(—Iv Services,Swbd.,MCC&Panelboards , Z
!!nn D 0-200 Amp.Under 600 V
Signature 201 - 1000 Amp.Under 600.V
Over 1000 Amp.or Over 600 V
E] Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
s
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 Circuitst'4 °
for the following reason(Section 7031.5,Business and Professions
Code): 3307 11-5.51D
.i Misc.Conduits&Conductors
❑ I,as owner of the property,will do the work and the structure Other(See Complete Fee Schedule) _ 1 ITEMS
is not intended or offered for sale (Section 7044, Business p
and Professions Code). , TOTAL 115.50
CONSTRUCTION LENDING AGENCY CHECK 115°�I)
I hereby affirm that there is a construction lending agency for the C-
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub Total) OSA ~`HAI��E ° ll
Civ.C.). Ili
PLAN CHECKING FEE
Lender's Name — 1]001]--LGO1 11 /24/913
PERMIT ISSUING FEE
Lender's Address 3488 1 ASI1L1:1
1 certify that I have read this application and state that the above TOTAL FEE
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 I
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
I
Signature of Permittee Date ,