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WORKERS'COMPENSATION DKLARA710N 76A663 i0i87 �pp«�ATI4N�� FOR �LECTR�ICI��L����P�RNIIfi ���-�
I hereby affi�m �hot I hove a cerlificate af mnsent to self CE-806G
ins�re,o�a�e�+ifi<ore of wo�ke�s'Compensatio�I�sura�ce, COUNTY OP LOS ANGELES SUILDING AND SAFETY �
or a certified copy thereof(Sec.3800, b.C.)
P❑ol�icy No.��Company� ��� FOR APPLICANT TO FILL IN DDRESS , � s!L '�
Certified copy is here6y furnished. New Residential Bldgs.&?ools EACH n�0. FEE
�Certified copy Is filed with�he couNy building Inspeo- 1&2-Fomily,Sq.Ft. $ = `� LOCALITY � ��
Mulli-fomily Sq.Ft. NEARE57
llon depart enL CROSS S7. /^..'�jq
Date A licant ii'T �,,y� Residentipl$wimming Pools OWNER OR
PP —" G� FIRM NAME�- �
� CERTIfICATE OF EXEMPTION FRO�M WORKERS' Outle�s:Rec�lighi�Sw._ N�Ait
COMPENSATION INSURANCE .� ADDR�.SS
First 20
(This setfion need not ba completed if fhe work 1�volvad by Total No. � Addi�ional CITY Tel.No.
�he permif is for one hundred dollars(5100)or less.) v�AN CtiECK
I cer�ify that�n ihe performance of-rhe work for which this qpp�ICANT
permit is issued,I shall not employ any person in any mpnner �i htin Fixtures Firsf 2D 6 ADDRES$
so as to become subject to the Workers'Compensation Laws. 9 9 ��
Total No.� Additional CITY �., Tel.No. � �
Dote �pplicant Fized Appliances Not Over 1 HP PERMiT
NOTICE TO APPLICANT: If, ofler moking rhis Cer�ificate of qpPLICAN7 /• [���'�^� '
Ecemption, you should become subjecf to the Workers' Ra^9e�Heoter_D.W._ ��
Compensa�ion provisions of�he Lobor Code,you must forth- Oven _Dryer _W.M.— AODRESS
� with comply wi�h such provisions or this permit shall be Top ._FAU —W.H.— ❑TY Tel.No.
deemed revoked. Hood �Fon _Other._
LICENSED CONTRACTORS DECLARATION �ICENSE OR
I hare6y affirm thot I am licensed under proaisions of Chap�er 9 Dlsp. _Room Air Cond. — REG.NUMBER ��'� C1oss. � r
(cammencing with Seciion 7000)of Division 3 of ihe Business power Apparafus 8 Large Appliances DISTRICT NO. � T PROCESSED BY pe
ond Professions Code,ond�my license is in full force and effect. Q �Z �
- Size 8 Type HP.KW,KVA,or KVAR
License Number���%���� Lic.Class "�� �p}o�����. FINAL d-`
Over 1 to 10�nd. DATE����� VALIDATION �
Conirac�or s'�"._—Dote �7 � O�er 10�o SO IncL V
❑ FINAL �3
I om ex t under Sec Over SQ to 100 Ina BY l�i�G�/� �'
8.8P.C,for Ihis reoson Over 100 �
Date: Services,Sw6d.,MCC&Panelboards ►
0-200 Amp.Under 600 V _
Signoture 201-1000 Amp.Under 600 V
❑ - Over 1000 Amp.or Over 600 V _
Exemption for Reg.Maim.Elect. � I 3 3.6 A
SINGLE FAMILY Temp.Power Pole 8 Appurtenances „ o a o
HOME OWNER-BUIL�ER DECLARATION U71 '� �
Sign witn One Branch Circuit
I hereby offirm ihoi I am exemp�from ihe Conirador's License qddi�iona�Sign 8ranch Circuifs ( e a C F:�(�`
Law for the following reason (Section 7031.5, Business and
Professions Cadel:
❑ I,as owner of the property,will do the work ond the Misc Condui�s 8 Conduc�ors � `�'"C`%'S C�`'S�
siructure is not intended or offered for sale (Seclion Other(See Comple�e Fee Schedule)_ , ���'7�.g�
7044,Business and�Professions Codel.
CONSTRUCTION LENDMG AGENCV �i ��'.7��'
I hereby affirm that there is a consfruclion lending agency for a, � o
the performonce of the work for which�his permit is issued PERMIT PEE (Sub-Total) S r/y> m� � �C
Sec.3097,Civ.C.
( ' PLAN CHECKING FEE � ` ° °�7�
Lender's Nome /A „ � �. ���e��
PERMIT ISSUING FEE
Lender's Address �f7' ����7_��
I certify thot I have read this opplimtion and staie iha�the TO7AL FEE d�' �
above informafion is correa.I ogree to comply with all County
ordinonces and State lows regula�ing Electriml w ing, and
hereby a�thorize represento�ives of this County to emer upon
rhe abave-merrioned property for inspection p r� SEE REVERSE FOR EXPLANATORY LANGUAGE
ignnt e�minee Dafe
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