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WORKERS'COMPENSATION�ECLARATION 76A663 �o�ai APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm thal I hove a certiiimte of consenl ro self CE-BobG . �
insure,or a certifimte of Workeri CompensaGon Insarance, COUNTY OF LOS ANGELES BWLDING AND SAFETY
'ra e`Sf��`p�rof{�c.3800,Lab.C.) , . .
5 qq
o�cy r7o. Cbmpany � fOR APPIICANT TO fltL IN � � � �OB
J Certified copy is here6y iumished. New ReSidentiol Bidgs.8 Pools EACH NO. FEE ADDRE55
Cerlified copy is filed with the county building inspeo 1 8 2-Family,Sq.FI. � S — E LOCAUTY
lion department. ��� �� Mulli-family Sq.FI. — NEAREST
1���� Q�► ) T' �� Residential Swimming Pools CROSS ST.
��Data �fL�'tY}7 Applican�(�1�-�.J_YLC4.�LI�P� OWNER OR
FIRM NAME
��i, CERTIFICATE OF EXEMPTION FROM WORKERS' � Oudets:Rec.�Light_Sw._ � Nj0'�� �
� � COMPENSATION INSURANCE - - � Firsf 20 ADDRE55 '
(iA�s secTien naed not be compl�tod il tho werk Involv�d by . Totol No.� CITY Tel.No.
Th�permif is for on�hundred dollers(5100)or leu.) �. Additional"
I terlify Ihal in the periormonce of the work for whith this APPIICAMK �� ' '
permit is issued,I shall nof emptoy ony person fn any monner �
so as to bemme su6ject�o the Workers'Compensotion laws. Ughting FixNres First 20 ADDRESS � '
�� � Tatol No.� Additianol �
Date npP���o�� � . � ❑TY 7e1.No.
NOTICE TO APPIICANT: If, a(fer making Ihis Certificate of Fixed Appliances Not Over 1 HP PERMI7
Exemplion, you should become subject lo Ihe Workers' Range_Heater_D.W,_ APPt�CP'NT
Compensotion provition5 of the labor Code,you musl forlh- Oven _Dryer _.W.M.� ADDRESS
with comply with soch provisions or this permit shall be Top _FqU —W.H.—
deemed revoked. � . - ' � CITY � Tel,No
� LICENSED CONTRACTORS DECLARATION Hood _Fan _Other, -
Disp. �_Room Air Cond. — LICENSE OR �1 ' . Claas.ea
I hereby aHirm thot I om licensed�nder provisions of Chapter 9 REG.NUMBER o�a"� 9
(commencing wiih Setlion 7000)of Division 3 of Ihe Business power Apparatus 8 Large Applionces. �ISTRICT NO.. PROCESSE BQ Y . Y
� '-and Protessions Code,and m license is in full force and cffect � - �.' . .. . � .. , � , d
y �f _ , ... . .
�7 �,� Size 8 Type HP,KW,KVA,or KVAR� ., l� ��„t��. p
-License NumberGZ+����Lic:ClasslLZly_ � � FINAL / � � V
1 Up to 1 Ind.
r J�l� A T ' �)„ � Over 1 lo 101nd. DATE �4 �3 D VAIIDATION �
�ContraQt4 e"i"a�L• ..»'..��irs�'`nole � 4 .
,,�❑ Over 10 to 50 Incl. FINAL �`
I am exempt under Sec. Over 50 10 100 Inc. BY W
8.8P.C.for this reoson Over 100 �'
H
� Daie: Servfces,Swbd.,MCC 8 Ponelboards - � ► - � - �- � z�
0-2W Amp.Under 600 V _
Signoture 201-1000 Amp.Undar 600 V � � � �
Over 1000 Amp.or Over 60p V r�3(�,Q�A .
�, � Eeemption for Reg.Maint.EIeU. ' `
f SINGIE fAMILY � Temp.Power Pole 8 Appurlenances #• • e • i'2
HOME OWNER-BUIIDER DECIARATION Sign with One Branch Cirtuit � • • � �Jr.o
� I hereby oH�rm that I am exempl from the Gontrodor's License Q�����c�������R.r,nrh Cirn�it< �
Law for the foilowinq reoson(Section 7U31.5,Business and •_.• •1 �5 O=
Professlons Code): , c%
❑ I,os owner of�he ro erf will do the work and�he Misa Conduits 8 Conductors � �
P P y� O�her See Com lete Fee Schedule_ ► 0�1,3�0-8 4 .
structure is not in�ended or o(fered for sale (Section � P )
. 7044,Business and Proiessions Code). � ��
CONSTRUCTION LENDING AGENCY . �� . . . .
�� I hereby affirm that there is a consirudion lending agency for .
� Ihe per4ormance of Ihe work for which this permil is issued �� pERMIT FEE � � � � �� � � (Sub•To�ol) �- - . . . _, .. .
(Sec.3097,Civ.C.J. � � �
� � PLAN CHECKING FEE �� -- �- � . . _.. ._ . . , � �
. Lender's Name
� PERMIT ISSUING PEE . � Q
� Lender i Address � � � �.
I certify thot I have read�his applicotion ond state ihat�he TOTAL FEE �3�`'Q . . .. ..
above information is correct.I agree�o comply with all County
ordinentes and$fate lows reguloting Elecfricol wiring,ond �
�� hereby outhorize representotives oi ihis County fa enler vpon , - � - � . -� . � - -
�he o6ove-me tioned properry for inspeclion purposes. „ SEE REVERSE FOR EXPLANATORY IANGUAGE.
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Signoture Permi�ree Date �
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