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WORKERS"COMP�N�LARATION 76A663 IOi91 � '
I Mere6y affirm �ha� I hdve a terfificafe of consent fo self CE-806G APPLICATIC?N fOR ELECTRICAL P�RMIT �
insure,o�a ce�tiflmre of Workers'compe�sorio���sura�ce, COUNTV OF l05 ANGELES BUILDING AND SAFETY
or o certi{ied copy thereof(Sec 3800,Lab.C.)
P�olicy No. Company FpR APPIICANT TO FlLL IN JOB .
Certified mpy is here6y fumished. New Residen7ial Bldgs.8 Pools �CH NO. FEE ADDRE55 t} 1✓X'J��4'..
� Certified copy is filed with the county building insper 1 8 4-Fvmily,Sq.H. s = 4 LOCALITY�ti LI�,VT
tion deporlment. Multi-fami�y Sq.Ft. � NEAREST
Residenfial5wimming Pools CROSSST, q��
Dofe AppliCant OWNEROR /��t .-f- "'/e
CERTIFICA7E OF EXEMPTION FROM WORKERS' � � �M NAME LT � YI C Z�9S
COMPENSA710N INSURANCE Outlets:Rec Light Sw.__., A��RE552? ��?At+SG/1c•dE
(Thi���cfion ne�d noi b�complet�d if Ih�work involwd 6y � " Firit 2D CITY((Jpe(_/1,��� Tel.N , � 5-ij
the parmit I�for ona hundred dollars(5100�or lass.) Total No. Additlonal �f
I ceriify that in Ihe performance of�he work for which�his A vN�CAE�C.K
permit is issued,I sholl not employ ony persan in ony manner
so as to become subject�o ihe Workers'Compensotion Lows. Lighiing Fix�ures First 20 ADDRESS
To�ol No. Addifional
CITY Tel.No.
Dafe ApplitoM Pixed Appliances Not Over 1 HP PERMIT �"�
NOTICE TO APPUCANT: If, ofler making this Certitiwre of AP%ICANT Vc�lvE-'' )
Exemption, you should 6ecome subjecr to the Workers' Range_Heaier_D.W.._
, Compensation provisions of the Labor Code,you must forth- Oven _Dryer �W.M._ ADDRESS
winc �omply with such provisions or �his parmif sholl be iop _FAU —W.H.._ CITY Tel.No.
deemed revoked. Hood _Fan _Other._
IICENSED CONTRACTORS DECLARATION UCENSE OR
I hereby affirm that I am licensad under provisions af Chopter 9 Disp. _Room Air Cond. � REG.NUMBER loss.
(commencing wifh Seclion 7000)of Division 3 of ihe Business power Apparalus 6 Large Applionces DI57RICT NO. PROCE55 BY �
ond Professions Code,ond my license is in ful)forca and effecl. � Q'
Size 8 Type HP,KW,KVA,or KVAR� .Q U
License Number Lia Class FINAL Ll.'
Up to 1 Incl.
Over I to 10 Incl. �ATE VALIDATION O
Coniractor Date Over 10 fo 50 IncL � W
aFINAL
I am ezempt under Sec Over 50 to 100 Inc. BY p:
6.SP.C.for this reasan Over 100 N
Z
��e_ Services,Sw6d.,MCC E Panel6oards � �((o,�.'/1(5'I�'�i�G�d��Cl �A��—
� 0-200 Amp.Under 600 V
Signature 401-1000 Amp.Under 600 V y/
QOver 1000 Amp.or Over 60p V ` }��1 6 d 1 A
Exemption for Reg.MaiM.Elect. �+ � �.2�l 5�
SINGLE FAMILY Temp.Power Pole 8 Appurtenances �� � � Q�
HOME OWNER-6UIlDER DECLARATION Sign wiih qne Bronch Circuit Q i,��'�"]
I hereby affirm�har I am exempt from the Convactor's license AddRional S�gn Branch Circuirs
Low for the following reoson (Sec�ion 7031.5, Business and
Pr essions Code):
I,os owner of the propeny,will do the work ond the Misc Conduits&Conductors
srrudure is not intended or offered for sale (Section Qiher(See Complere Fee Schedule)_ ►
7044,B�siness and Professions Code).
CONSiRLICTION LEN�ING AGENCY
I here6y affirm that 7hera is a wnslrucfion lending ogency for
the performance of ihe work for which this permit is issved PERM�T FEE (Sub-Totol) �'
(Sec 3097,Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSU�NG fEE �
Lender's Address
I certify thot I have read fhis applimtion qnd srote thai rhe TOTA�FEE aS
above informotion is torrecL I agree 7o comply wi�h all Couniy
a�dinances and Slale laws regulating Elecfriml wiring,and �
hereby authorize rep�sentotives of this County�o enter upon � -
� the abo e-mention` p er 4for inzpedion pvrposes.
,1 / .q SEE REVERSE FOR EXPLANATORY LANGWAGE
� ci �� �"O �
Si alure o4 Gzrminee Da�e �
� h'�' �'� ,Ik ';� . �.� ' ���'�� �' .J1 �`�+i e . . , .
1 ar��VF,I�� DATz `--' 4'JJNER-BUILDER OFCLARATIO�:
. . . �.. _.�v^... SsC�NATUkF . _ . .
� . �. .�a���.s._"
� ' -� •.�,F i��p��E : � � I hara6y nffirrn t4io,I nn excmpt from}ho Confractor'R
� � �-�---�-----------� 4i��rsro 4avr far t!�� 6olicwiny renson (Section 7031.5,
___ ,
� �- U�.D£RSx �� itK �� - � � 6�sinsss an�'pro(9ssions Codej�Any dty ar cnunty wh1cF
_.__. c.�__�_.._..._._
-"--'"j
�,�� � ,���t�,. �eqvtres c permit to tonsfruct,olter,�mprovv,demol7sh,
� � � or r�+�ir�any st udure,p�ior fo its issuanca atso re-
. . . �-..�._...._.
.. ___.__ _._._ ._....,....�__._..._.
t},r p7f.r,� � � qutr�s F5�ag�n 7 a-rt for auch pe:rnit to}ile a slgnad stole- .
. �-- .. -----j- -..�' - ��� '� ; mcnt Yh74 he is llc�ensa3�vrsuont ro the provislonz of ihe
.. .F.XTURE� �
. � .�_ ' __��_,,,...,� � Corsfro.�fori Ll�ense Lcw(Chdpfer 9(ccmmettcing wifh
� �� - � � . fD�iE'n AJFI'G`�-�.D � � . Section TQ�)d Divisfon 3 af the Bvsiness und Profes-
�-------� stnns Cods;or 7'na;ke ls exempt tFerefrom and+he bnsis
U I�:TY�CLI R�T�l.'.C1�~ T � ¢or ti�u cfl.:ged euempiion. Any violction or Sortion
F�hAt� �f ��� � 703L5 6y anN apFztitcnt for a permit subja.ts!he appli-
. � � C r�$¢r ort _.-razef eant fo a e1vU penalry of no�more than Iiva hundred
.__..__�._._... _..—..r__^...,._.,...___
.. . -`JOTFy � dot(ars($SOOf.'
. - � - ' � � � ❑1,os owner af the�prpperfy w111 dc the work,and
- � � _____�,�„�_„�_ ,_______�_.�,,,�,�. lho��truuture is nat intonded or ofieretf{or sola.
� {Sr�a 3t74�,8astnuma and Pro{asatons Coder Tbe Contror
____..,.-__,,.�.�.._____..._._______���..�_ .. , t�.*'s Ltc�nse Lcw daas not cp�ty�o an owner of p�operty
� , who 6uilds or�lmptovrs tfierean, ond vsho does s�cb
� - � � � � � � � veork himse(t provldnd thnt surh�improvements are not
_.____ __._..—_ __ .�___.... - - . - 7Me.3nded or olfere3 for salc.It,ho�vcvsr,tho bulfdin�or
_,,, ImprQvemeni is so!d wifhin orta yeor oi cnmple>ioo,tho
.�..�. _.�_-_____.._..._........ _._._..__........__.._.._ .r_�..�._,_ .
� � an•ner-butld�t wftl have the Gurnen of proving tfict he d'rd
� � � �� _� � na'bu1ld or improve for the purpase of sote.)
� I am ex��npt undar Sec.___.__ •
-.�....._._,_.,_,_.-.._�----._�.___^_.�__....._...-------- � — . 6&.P.C.for this r�aosori_..
__..__.._. . __._.......—_..._-----�-- -----..1,--� �.�_..
�
� . . Date� �-----
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