HomeMy Public PortalAbout9822 WINDSOR LN_Electrical__ I
WORKERS'COMPENSATION DECLARATION 78-810/e1 APPLICATION FOR ELECTRICAL PERMIT
CE-8080B G
I here�Y affirm„that I have a certificate of consent to self insure,
or a 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
'! d
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS
J-nr $FtLOCALITY � L IT
S
2-Family, q. . 1
— $ fJ P� Y
Certified copy is filed with the county building inspection 1 & NEARESTST.
department. Multi-family Sq.Ft.
ROSS
C
Date Applicant Residential Swimming Pools OWNER OR
FIRM NAME 4—P S+C,
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 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 p45 G o
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
p Additional
Date to 2rf—�G Applicant 6t p' Q t JjC_ Total No. CITY Tel.No.
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT • 1� i
Exemption,you should become subject to the Workers'Compensation Range_ HeaterD.W. _ APPLICANT 6V /J �'j1+e� ''�-
provisions of the Labor Code,you must forthwith comply with such Oven _ Dryer_ W.M._ ADDRESS
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ CITY"~.1544 Lpe C r Tel.No. 7
LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_
1 hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class. C
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER V( v
Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances DISTRICT NO.v 1 � U
PROCESSE BY Q
C G Size&Type HP,KW,KVA,or KVAR /
License Number—. 4 v o Z 7�� Lic.Class Up to 1 Incl. FINAL
Contractor G ClfeG-h.LDate -'L �6� Over 1 to 10 Incl. DATE-Z-�� �t� O
N
VALIDATIO
❑ Over 10 to 50 Incl. FINAL 0
I am exempt under Sec. Over 50 to 100 Inc. BY
B.&P.C.for this reason Over 100 / N
O ZL( (� Services,Swbd.,MCC&Panelboards ® e Z
Date: 0-200 Amp.Under 600 V E'
Signature 201 - 1000 Amp.Under 600 V
❑
Exemption for Reg Over 1000 Amp.or Over 600 V
aint.Elect.
t SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit ?.
1 hereby affirm that I am exempt from the Contractor's License.Law Additional Sign Branch Circuits H�GTsZ
for the following reason(Section 7031.5,Business and Professions
Code):
Misc.Conduits&Conductors `307 115n5L.
I,as owner of the property,will do the work and the structure
is is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _
IE
and Professions Code). Poo. TOTAL 115 m 50
CONSTRUCTION LENDING AGENCY HECK 115.5131
1 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) CHANGE ,1177.1
Civ.C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE
Lender's Address 3490. 1 AMICI a 12
1 certify that I have read this application and state that the above TOTAL FEE
information is correct.I agree to comply with all Countyordinances i
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
Signature of Permittee Date