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WORKERS'COMPENSATION DECLARATION � ��. � 7en66i �o,e, �APPLICATION FOR ELECTRICAL PERMIT �
I here6y offirm tha�I have a cartificate of consem to self" �E'�
� insure,or a certificate of Workers'Compansation Insuronce, COUNTY OF LOS ANGELES BUIIDINIi AND SAPETY
or o ceriifiad copy lhereof(Sec.3800,lab.C.)
P�olicy No. Company FOR MPIIGM TO FILL P! JOB L•`
Certified copy is hereby fumishad. Naw Residentiol Bldgs.8 Pools �H �' FEE AODREu 1�f p� C��ti� n
� 1 8 2-Famil FI. s — f IOCALITY �.iy...a� �t�t,
Cartified copy is filed with fhe coumy building inspeo Y�5q�
�ion de �tment. Multi-inmil F�. — NEAREST
P° Y�� CIt055 5T. 4 L c.�.r+s Lf/t�wl�
Residentiol Swimming Pools pWNER OR
Dafe A licont
PP FIftM NAME �2•r S Jl B✓/
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlels:Rec_Ligh1_Sw._ �� ' N
COMVENSATION INSURANCE AODRESSI�'7 {"�• U/L(r�� f Kr C Sk�
This s�ion n��d'rot b�com I�Md I}th�wo.k{molv�d 6 Firs�40
� P r Total No. Additional CITY�-G.ar� N+ Tal.No. -d'ZS
16�p�rmN is for em hundnd dellan(5100)or bss.) ,
I certify ihot in the per(ormance of the work fo�which this . ' � q�i�qMK
perm�t is issued,I sholl not employ ony person in any manner
so as 10 become sobjeU to the Workers'Compensafio�laws. lighting Fixturas First 20 AODRE55
� Totol No. Additionol
CITY Tal.No.
Date Applicani Fixed Apphances Not Over 1 HP PERMit
NOTICE TO APPLICANT: If, after making this Cer�ificate of AiwIICANT
Exemption, you should become su6ject to the Workan' Ronfle_Heate�_D.W._
Compansation provisions of the Lobor Code,you must forfh- Ovan _Dryer _W.M.— ADORESS
ith comply with such provisions or this permit sholl be 7op _FAU —W.H.—
deemed ravoked, Hood _Fan _Ofher_ CITY Tel,No.
LICENSED CONTRACTORS DECLARAT�ON uCENSe Ort
� I he�eby aRirm lhar I om licensed under provisions of C6opter 9 Disp. _Room Air Cond. — RE(4.rIUMBER Class.
� (commencing wcth Secffon 7000)oi Division 3 of the Business power Apparatus 8 lorge Applioncas DISTRICT NO. PR SSED BY �,
ond Professions Code,and my licanse is in tull iorce ond effect. O �C�H� y
Size 8 Type HP,KW,KVA,or KVAR � ���� p
� litense Number Lic,Closs Up to 1 Ind. FINAI V
CoMractor Date Ovar 1 to IO lnd. DATE �� n� �i� yp��DAT10N Q
c�
OOver 10 to 50 Incl. fINAL ~
I am exempl under Sec. Ovar 50 to 100 Inc. BY W
B.BP.C.for Ihis reason Over I00 -��"Lt~'� Z�
�ate: Services,Swbd.,MCC 8 Panelboards ► �
, D-200 Amp.Under 600 V
S�gna�ure 201-1000 Amp.Under 600 V -
� � Over 1000 Amp.or Over 60p V
Exemption ior Reg.MainL Elect.
SINGIE FAMIIY Temp.Power Pole 8 Appor�enances � �O 2 Z.�i A
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit
I hereby affirm ihot 1 am exempt from�he Conlractor's license Addifional Sign B�anCh CircVifs t` • • • e.�2
Law for the fallowing reason(Section 7D31.5,Business and
�Pro ssions Code)� � s e 2 5,5 fl
I,os owner of ihe property,wiil do the work ond Ihe Misc.Conduils 8 Conductors � ��0
s�ructure is not intended or oHered for sale(Section O�her(See Complele Fae Schedule)_ °L J..�i l7 c.=i
7044,Business and Professions Code). , J �,��=fi j
CONSTRUCTION LENDING AGENCY
� I hereby offirm ihof lhere is a consfruction lending ogeocy for
the performance of ihe work for which this permit is issued pERMIT FEE (Sub-Totai) 'r �
� (Sec.3097,Civ.C.J.
� PLAN CHECKING FEE � .
� lender's Name �
PERMIT IS5UING FEE O �
Lender i Address � �,
I cenify that I have read this appiication ond sta�e tha�the TOTAL FEE
above ini t�on is corracL I ogree fo comply with oll County � ,
ordina s nd Srate laws regulorin9 Electrical wiring,and . .
her orize representatives of Ihis County to enfer�pon
th ve-m �io d o �t (or inspection purposes. SEE REVERSE FOR EXPIANATORY LANGUAGE
i�,r3 �3
Signoture of Pe�mitte Dale , .
-APPROVALS � -DATE / . � OWNER-�UILDER DECLARATION
C ATIIR
. 7EMP.,POYJER POIE �� �J I hcreby affirm Ihot I om.exempr from 1ho Contr�Uor's
� license Law for tho following reazon (Secflon 7031.5,
� UNDERSLAB WORK _ . � Bustness end Pro/essions Code):Any Nty or county which
� . . , � ROUGH CONDUIT � -- - - � �' � reqvfres a pQrmif lo eor,truc},allcr,Improve,demolfsh,
. . _ � . . _ or ropalr any strutture, prlor fo Its issuanco, nlso re-
,� WIRING . quires fhe oppllcanf for such permlt lo flle a signeds�v�e�
- - FIXTURES men}fhcfFeltllcensedpu�suanttofheprovisionsoiiho
� � � � Conirocfori Lfcense Lew(Chapler 9(commenUng with
. � POWER AUTHORfZED �7�y�" �, ,��` Secllon 7000J of D)vislon 3 of Ihe 6uslness and Profes-
sions Code)or Ihot he Is exempt fhcrefrom and fhe bosis
� - -� � UTILITYCO.NOTIFIED� for fhe alfeged oxempNon, Any vfolaflon of Secffon
� FINAI - -L' ' � ' � 703L5 by any applicant(or a permlf aobJetfs fhe appli-
_ nlei on ron[ cvnt lo a eivil penalfy o/no�moro}hon/!ve hvndred
- NOTES � - . � , - � dollars(5500).:
, _ ❑I,as owner of fho property will do tho work,ond
� tho shucWre is not iNended or offcred for sale.
� � (Sec.704�,Buainass ondProlosslons Code: Tho Confroc-
- �o�s Ueensc Law docs no�opply fo on ownor o£property
� - -. . _ _ , who bWfds or fmproves ihcreon, and wbo does such
� work hlmsolf provldad Ihal such Improvements are no�
" ' ' � - - � � _ Infended or oifered lor sole.!f,however,Ihe 6vilding or
Improvoment Is sold withln one year o(completion,ihe
'��l . , , . owner•6ul7der wt1!have fho burden of provMg�ho�ho d�d
- not 6ulld ar Improvc!or the purpose o/sale.J
I am exempt under Sec. , .
. B 8 P.C.for fhis reason
�
Dote
Owner
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