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\VORKGRS'CO\tPENSATIONDECL.ARATION - 76a663 APPLICATI�N FOR ELECTRICAL PERMIT - � �
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I hereby affirm that I have a certificate of consent to se�t COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of R'orkers'ComDensation Insurance,or � � . . _ �
a certified copY ihereof(Sec.3800,Lab.CJ �
(r� I� FOR APPLICANT TO FILL IN JOB �L��
� PolicY N "����t;ompany��� S�� �N"�� � EACH NO. FEE AODRE55 fyY �
New Residential BId9s.&Pools
� Certifed cnpy is here6y furnished. � 1&2-Family,Sq.FL $ — $ LOCAUTY ��'py�.�
Multi-family Sq.Ft. N ARESi
Certified copy is filed with the county building inspection C RO55 ST
Residential Swimming Pools
department. . F�RM NAME rr {J �� . ..
Dates��z Applicant ���Cs+yn��� Outlets:.Rec._Li9h[_Sw._ ADDRESS ���R
FirSt 20 '
CERTIFICATG OP LXtih1PT10N FROM WORKEiRS' Total No: Additional CITY - 7el No. � .
� COAIPCNSATION INSIIRANCG a
, PLANCHECKraut� ' ^ _
(This section need not be completed if the work 10�'OlVfd APPLICANT L e p
Lighting FixtUres First 20 , AODRESS V
by the permit is for one hundred dolla�s (5100) or IessJ 6 ��4� �
- . Addi[ional
- Totel NO. CITY Tel No. �,/ O
1 certity ihat in the performance of the«•ork for which this Fixed Appliances Not Over 1 HP �� �• �
permit is issued,t shall not employ any person in any manner, PERMIT U
sn as to become subject to Ihe Wnrkers'Compensation Laws. Range_Heater D.W._ APPLICANT 4 YV�'Q W .
. Oven'_DrVer_W.M._ qOORe55 N �
Date Applicanf Top _FAU _W.H., . Z
� � Hood_Fan _Other_ CITY Tel No.
NOT[CE TO APPLICANT:[f,aCter making this Certificate of Disp. _Room Air Cond._ LiCenlsE OR q �r79� /+p!
� lixemptian, you should Hecome subject to the Workers' REG.NUMBERJ J7 Class C.. {
Compensation provisions o[the La6or Code,you must forth• Power Apparatus&Large Appliance5 DISTRICT NO. PROCES E�BV � '
with comply with such provisions or thls permit shall be Size&Type HP,KW,KVA,or KVAR � /D
deemed revoked. Up to 1 Inel.
PINAL '
' Over 1 ta 101nc1. oA7E VALIDATION
LICENSED CON7RACTORS DECLARATION Over 10 to 50 Incl.
i hereby atfirm that 1 am licensed under provisions of Chapcer. Over 50 to 700 Inc. By AL - .
9 (commencing with Section 7000)of Division�nf Ihe Ausi• Over 100
ness and Nrofessinns Code,and my license is in full forte and , .
effect. • - y"� Services . '
License Number��Lic.Clasa � •� 0�200 Amp.Under 600 V . ,
/� 207-1000 Amp.Under 600 V
Contractor��v�hG)I�AC)Date.��� Over1000Amp.orOver600V �
H0�1L OWNF.R-BUILDER 0£.CLARATION Temp.Power Pole&Appurtenances _ � '
1'hereby affirm thaf 1 am exempt irnm the Contrsctor's Sign with One Branch Circuit ^ ,
Additional Sian Branch Circuits �Q 4�.�A
License La��f�r Ihe f�llowing reason(Sec�ion 703I.5,Busi• , i
nessandProfessionsCode): , � ���i•�•,�i�2
Misa Conduits&Conductors • �
� I, es owner ot the property,will do the work and the Other ISee Complete Fee Sthedule)— ��.�:�2 Q 5 Q
structure is not intended or offered for sale (Section , • �� �
7D44,Business and Professions Code). . 2
�CONSTRUCTION LGNDING ACENCY � � �_`�:�2 O.J�O c�
1 hereby offirm that there is a construction lending agency - �
for the performance of Ihe �vork for�vhith lhis permit is pERMIT FEE (Sub-Total) v � I 0 2�y 8;1
issued�(Sec.J097,Civ.C.). . .
Lender's Name _ PLAN CHECKING FEE (One•Fourth Permit Fee) �
Lender's Address PERMIT ISSUING FEE � �
1 certify that 1 have read this application�nd state that the TOTAL FEE �',(J
above information is correct.I sgree to comply with all County . ' �
ordinsnees and Stafe laws regulating Electrical wiring, and .
�hereby authoriz re e tat'ves of this County to enter upon � �� - � � -
the a ve-men ne e y for inSpeUfnn purposes. � _
A SEF.'REVERSE FOR EXPLANATORY LANGUACC �
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