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WORKERS'COMPENSATION�ECLARATION 76A663 i0i8t pppEiCATtON F4R ELECTRICAL PERMIT /�
1 hereby affirm thot I have a certi{icate of consen�to self CE-806G ry'
insure,or a certifimre ot Workers'CompensaHon insurance, GOUNTY OF LOS ANGELES BUILDING AND SAFETY ��
� or a certi4ied copy thereof fSec.3000 Lob.C.) U
Policy No��tl�mpan,�.�t�►ti�n ��� FOR AiPUCANT TO FN.L IN DDRE55 � �
1 � Certified copy is here6y furnished. New Residential Bldgs.8 Pools EACH NO. fEE
� O s = g LOCALITY m
Certified copy is filed wilh�he counly building inspeo- 1 8 2-Fomily,$q.Ft.
1 lion deporfinent. � Multi-family Sq.Ft. CR�55 ST
� Q1` Residen�ial Swimming Pools OwNER OR
I Oate�I��Applicani �� FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._ ���
' COMPENSATIOhI INSURANCE ADDRE55 M ��
First 2(1 �
(Thls s�elion nwd nol l»complN�d if th�work involv�d by Total Na. Additional CITY Tet.
tho p�rmii is for one hund��d dollon(;100)or loas.) PIAN E
I certify�hai in tha perfarmance of the work for which this AV�ICANT
� permit is issued,1 shall not employ cny pe�son in any manner
so,r•�o becoma s�bjaci to the Workers'Compensation taws. ��9�'ting fix�ures Firat 2D _ AD�RE55
� Addiriorro4
� Totol No. CtTY Tel.Nn.
D^te APPlicanl Fiaed Appliances Not Over t HG pERMIT 1 '
� �ICE TO APPLICANT: if, after moking this Cerfificote of qpp����
..:mption, you shoold bemme subjed to �he Workers' Range�Hcater_D.W..—
Compensa�ion provisions of ihe Lo6or Code,you must forth- Oven _Dryar _W.M.— ADDRE55
with mmply with such proviaions or fhis permit shaif be 7op _FAU —W.H.—
deemed revoked. Hood _Fan _pther_ CITY� , Tel.N �
IiCENSED CON7RACTORS DECLARAiION uGEt�uSE OR � C'�s i t ,�/`
t herehy dHi.m that�om licensed�nder provisions of Chapte�9 Disp. _Roam Air Cond. _ REG.NUn�eEk � `!a'r"f ��Ou•t..G�7
(commencing with Section 700pj of pivision 3 af the Business DISTRtCi NO- PRUCE D BY �
ord Professions Code,and my license is in futl force and effeci. Power Apporatus 8 Large Appliances �
,i Stze&Typa HP,KW,KVA,w KVAR U
License Number Up to 1 fncf. FINAC
Z.�,�Z,��'"F7lk.Class d.'
/jhlL,���� ,�� Over 1 io 101nc1. DATE �� c x VALIUATION �
controUor I/ L Over 10�0 50 Intl. �C�� � �
❑ FINAI W �
1 am exempt under Sec, Over 50 to 100 Inc. BY d
B.BP,C.for this reasan Over 100 Z
Services,Swbd.,MCC 8 Panelboards � ;
Dnte: p_ppp pmp.Under b00 V M
SignaWre 201-1000 Amp.Under 6W V
� Over 1p00 Amp.or Over 60p V
`xemption for Reg.Maint.E1ecr.
` SINGLE FAMILY Temp.Power Pole&Appurtenencea �'
HOME OWNER-BUILDER DECLARATION �
f ' � Sign with O�e&anch Ckcuit �
� 1 hereby aHirm Ihat I om exempr from�he Conhoctor's ticense qdditional Si ng�nch Circu�, _
Law for�he following reoson(Section 7031.5, Business ond �,," �('��i�9��
Professions Code): t� C �Q$9�7 A
❑ I,as owner af�he property,wili do�he work and the Misc.Canduits&Conductors
Other See Com lete Fee Sehedule_ ���� • ��
structure is not intended or offered for sale (Section � P � �
704A,Business ond Professions Codej. � � �3 a 5 Q
CONSTRUCTION LENDING AGENCY � ` ' � �
1 hereby affirm�hat if.ere is o mnstruUion lending agency for ��2�����U
the performonce of the work for which ihis permi�rs issued PERMIT FEE (Sub-Total) " �
(Se[.3047,Gv.C.).
PLAN CHECKING FEE
Lendar's Name
PERMIT ISSUING FEE
Lender's Addreu
I certify tho�I have reod this application and stare that the TOTAL FEE
above informa�ion is mrrect.I agree to comply with all Coun�y
ordinances and Slote laws regolating Electricol wiring,ond
hereby a�thorize represenlotives of this Covnty to enter upon
the obove-mentioned p�operty to� nspecrion urposes. SEE REVERSE FOR EXPLANATORY 4ANCaUAGE I
�J.ac'!C� I�` t� ��2.n�54� f
Signat��e of Permi ee �— Dat_-e�� .
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