HomeMy Public PortalAbout9821 WINDSOR LN_Electrical__ WORKERS'COMPENSATION DECLARATION 78-863 10/81
CE-aoeG APPLICATION FOR ELECTRICAL PERMIT
I hevpb),affirm that I have a certificate of Consent to self insure,
or if 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 A�,�,y e
` EACH NO. FEE ADDRESS �� Mbd�� �/7 /Y 15
❑ Certified copy is hereby furnished. New Residential Bldgs.&Pools
od $ — $ �`✓ 4,v% i
❑ — LOCALITY
Certified copy is filed with the county building inspection 1 &2-Family,Sq.Ft.
department. Multi-family Sq.Ft. NEAREST
Residential Swimming Pools CROSS ST. Qp
��-f/K ��
Date Applicant OWNER ORn,,�
FIRM NAME 4 G
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
permit is for one hundred dollars($100)or less.) Total No. Additional CITY Tel.No.
I certify that in the performance of the work for which this permit PLAN CHECK �t
is issued, I shall not employ any person in any manner so as to APPLICANT S V
become subject to the Workers'Compensation Laws.. Lighting Fixtures First 20 ADDRESS
�(� �
Data 10 "Z"o Applicant G`e-eJ�- Eik4 , �- Total No. Additional CITY Tel.No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT /± y /
Exemption,you should become subject to the Workers'Compensation Range_ Heater_ D.W. _ APPLICANT 644
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS 6- (f nj;;)p -,—L/
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ i
CITY 101_LICENSED CONTRACTORS DECLARATION Hood — Fan _ Ofher_ �y G D Tel.No.7+� (g
1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond.
LICENSE OR
.(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER G Class.
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO. PROCESSED BY
i
L/60�� Z Size&Type HP,KW,KVA,or KVAR 1- _ 0
G
License Number Lic.Class Up to 1 Incl. FINAL l� �0/
Contractor �s `� ✓l��"L Date 'YI Over 1 to 10 Incl. DATE 2- Z VALIDATION 0
Over 10 to 50 Incl. FINAL ®%
LLI
❑ I am exempt under Sec. Over 50 to 100 Inc. BY L
BAP.C.for this reason Over 100 N
Dat Services,Swbd.,MCC&Panelboards ® Z
0-200 Amp.Under 600 V
Signature 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
I hereby affirm that I am exempt from the Contractor's License Law ADL.T e a
for the following reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits
Code): 33137 115.513
Misc.Conduits&Conductors ' T
❑ 1,as owner of the property,will do the work and the structure 1 ITEMS EMS
is not intended or offered for sale (Section 7044, Business j Other(See Complete Fee Schedule) _
and Professions Code). ® TOTAL 115.50
CONSTRUCTION LENDING AGENCY CHECK 11505,
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) fa I CHANGE .013
Civ.C.).
PLAN CHECKING FEE I
Lender's Name _ 0000—[IDD 1
PERMIT ISSUING FEE PX
_ -
Lender's Address +3489 1 AM10-22
I certify that I have read this application and state that the above i 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
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date