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r� WORKERS'COMPENSATIONDECLARATION 76A863 APPLICATION FOR EIECTRICAI PERNIIT �
cEsosc�a-aoi
� 1 hereby attirm that 1 have a certieicate of cansent to setf COUNTY OF LOS ANGELES BW LDING AND SAFETY
; insure,or a certificate of Workers'Compensation Insurance,or . . �
a certifted copy thereof(Sea 38�0,Lab.C.)
� � - FOR APPLICANT 70 FILL�N �pg
� Poiicy No. Company ADORESS
New Residential Bldgs.&Pools EACH NO. FEE ��
�. �� Certified copy is hereby furnished. 1&2-Family,Sq.Ft. � � "' $ LOCALITY
' Mulii-family Sq.Ft. — A T
i � Ceriified capY is filed with the county building inspection Residential Swimming Pools CROgS ST AJ
department. � � � OWNEROR
L/ FIqM NAME
�+ Date Applieant Outlets'.Rec.._Light_Sw.? �O 3 AODRESS
/ First 20
' CERTIFICATE OF EXEMPTION FROM R'ORKERS' ToWI No.�Z Additional C�TY Tel No. �.
COMPENSATION INSURANCE � � PLAN CHECK C
. . APPIICANT � O
- (This section-nced not be completed if the wo:k involved ��yhting Fixtur s First 20 V
by the pecmit is for one hundced dollazs($100) or less.) AOOREsS �
. Additionel
. I ceRify that in the performance of the work for which this TOtel No. C�TY � ` Tel No. O
ermit is issued,1 shall not em lo en Fixed Appliances Not Over 1 HP U
p p y y peraon in eny manner PERMIT %� dR � a
so as to become subject to the Workers'Compensation I,aws. Range._Heater_D.W._ APPLICANT F�
. Oven _Oryer_W.M._ AOORESS � z
Date Applicant Top _FAU _W.H.._
Hood�Fan _Other_ . GTY Tel o. Z .
NOTICE TO APPLICANT:If,a[ter making thts Certiflcate of Disp. _Room Air Cond._ L CENSE OR -
Exemption, you should become subject to the Workers' � REG.NUMBER Cless
Compensation�ptovisions of the Labor Code,you muat focth- Power Apparatus&Large Appliences DISTRICT NO. PR ESSED BY
-with comply wiih such provisions or [his permit shall be Size&Type HP,KW,KVA,Or KVAR �
deemed revoked.
Up to 1 Incl. ��
FINAL
Over t to 10 Incl, DATE /ry Q'
LICENSED CONTRACTORS DECLARATION . Over 10 to 50 Incl. V —U VALIOATION �
I here6y afPirm that[am licensed under provisions ot Chapter Over 50 to 700 InC. FINAI
BY
9 (commencing with Section 7000)of Uivisian 3 of the Busi- Over 100
ness and Professions.Code,and my license is in fuil force and .
eriect. SeRvices 4. f C F E�;';
0-200 Amp.Under 600 V ScfQ� 't' `' • �° ° `
License lVum6er Lic.Class y01•1000 Amp.Under 600 V ' � • c��.y,�;
Contrector Date Over 1000 Amp.or Over 600 V � � � r•7��� - "�
G�L(`�.(;'�f�.��'.
HOME OWNER-BUILDER DECLARATION Temp.Powar Pole&Appurtenances . �
I hereby aff'um that I am exempt from the ContractoPs Sign with One Brench Circuit � � � .
�License Law for the fotlowing reason(Section 7031.5,Busi- Additional Sign Branch Circuits
ness en oPessions Code): � � �
Mix.Conduits&Conductors �
I, as owner of the property,will do the work and the . pther(See Complete Fee Schedulel—
strucYure is not intended or oftered for sale (Section �
7044,Business and Professions Code). .
CONSTRUCTION LENDING AQENCY
1 herebY aftirm tha[ Ihere is a construction lending ngency .
for the performance of the work for which this permit is� pERMIT FEE (Su6-Totall �
issued(Sec.3097,Civ.C.).
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
I certify that I heve read this application and state that Ihe � TOTAL FEE &%
above information is correct.I egree to comply with all County
ordinances and State laws reguleting Etectrical wiring, and �
hereby BUthoriza representatives of this County to enter upon �
abo�e-m ioned prope ty for inspection purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE � .r
��' Y��8/
Si �re of Petmjttee Dete . - � � � �
�
' Ti1��i� ��;��; � r� �C',� ►�p�T A}r J1'�J� ' �. ,
, r#,,� _.� . -.� OV�fERR,-BtIF#.➢E$BECF,AI�tl7hPl�i
.. . .. . . � - . 1 hereby a°�ir+�thet F aai cxet�rpf ilam the Co�aetor's
aPa�o�in�s o�.re �N"�'L'� Licexse Law for tLe folluH�ing rea�n/Secrion 7031.5,
. . _ s�crvnsuseE� . . Businzss and H�ofessions Co�e/: :kn3� cety or caunty
� � TEmP.POwFP ao�e ` � � whicla requr;es a permit�to construci, e!ler, i+r.pr�ve,
' � � - ' u�oeas�asvfort� � '� demolish,or repsir any structure,priur to r�s issumtre,
., � � aleo requires the applicant for such permit to file�d
��-� � � . ROUGF�Co�oUi'i' ,I, - - se;�ned smrement thne he is licensed pursuant ro�the
tr provrsions oj[he Coatmcror's License Law(Chapter 9
- � � � i�'�;t?ir�c l
_ (mn;mancir,;; with Secrion 76FM/ oJ Atviaion 3 oj the
� . . • FIXTURe� . . �� Ee:siness arr�Professronr Code/ or thrsi he is ezempt
aawzF quTHORizeo . . therrfrom mr�ilre hasis for theaFte�ed e�empreoK.Any
. viofation af St�ction 7031.5 by arry�appticaret jar o perrnit
. . .. . . _ u'riLiTv Co.n;o7iFifo� srbjects th.e cpnlicent ro a civil penalty of not raore thnn
— five hu.aCred dof�rs($SOOJ.: ' �
�FiNa� L'ss.� prs �2r,�s� - ❑f,as ow�net of tlie property uill do the work,and
� rvorEs tl�c siructurc is rat int¢ndeA or offeied for ssfe.
� � (Sec. 70J1;Businers a�d PYofeseirHes Cod�: Thc Crin�
� , trxror's Lieevtse Lew dves rrot apply �a a+r owwer of
. . praperty wlm fiurAds or improv:s thereon,ared x�Ho does
� � � � � � si+ch work hirxselJ pr�vided �lxet saek rmFravemerets
. .. . , ore ieot irttcw�tcvf or c.f�'ired Iba�. If� hewe{�r, the
� . . � .buikluag or improvement i.r ,sotrl H�it{+in one year of
� ---- � correpletron, the owrrer-Iwrkk�r wiF! have thr�burden
. .. . . . . �. ' � . oJ pvnvirig rlraa l�e.deri not MriJd or i,nprorc far the
. . - . P�+'P��f�J � �
� --`"-_ I aa�exempt under Sec. ,
B&P.C.for ihis reason
' D::te
OKmer
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