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WORKERS'COMPENSATION�ECLARATION 76A663 ,o,e, APPLICATIC?N FOR ELECTRICAL PERMIT �
I hereby affirm that I have a ceriifiwte of consent fo self Ce�06G
insvre,or a certifimte of Workers'Compensmion Insurance, COUNTY OP�OS ANGELES BUILDING AND SAFETY
or a certiL4iad copy ihereof(Sec.3800,Lab.C.)
P❑a�lcy NN�6:3�.3 Company S t.. �F U�'1 fI . POR A�PLICANT TO FILI IN ��B
�rtified copy is hereby fumished. New Resideniiol Bldgs.8 Pools EACH NO. FEE ADDRESS �I 2�S Ah t e n a
Certified copy is filed with Ihe coun building inspec- 1&2-Fomily,$q.Ft. s — S LOCALIN Wd��U t
lion departmem. Multi-family Sq.Ft. CROSS ST.
'��,�J„t�J Residential Swimming Pools OWNER OR �
Date Applicanf FIRM NAME L u mb r e s
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw.�_ ���� .
COMPENSATIDN INSURANCE AD�RESS
First 20
(This s�ction n��d not b�wmpl.t•d ff th�work tnvolvd by Total No. Addilional CITY rBi.n,o.5 g�—���6
1be permit i�for ona hundr�d dollors(¢f00)or leaa.) .
I certify ihat in the parformance of the work for which ihis � � q uCANTK
permit is issued,I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Lows. ��ghting Fixtures Firs1 20 ADDRESS �
� Total No. Additional CITY Tel.No.
Date /+pplicpnt Fixed Applionces Noi Over 7 HP PERMIT
NOTICE TO APPLICANT: If, ofter moking ihis�Ce�lificofe of APPLICANT m e r. S.o 1 .a r K 1 Il S E a r
Exemplion, you 5hould become subjetl to fhe Workers' Range—Hea�er_D.W._
Compensotion provisions of ihe Labor Code,you must forih- Oven _Dryer —W.M.— ADDRE55��.S Z�j, �S. S i n c 1 a i r
with comply wilh such provisions or this permi� shall be Top _FAU _W.H.— "
deemed revoked. Hood _Fon _Olher_ C17Y -Afl 8 I72 1 fil Tel.No. 8_ Z 2
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm ihot I am licensed under pravisions of Chopter R �isp. _Room Air Cond. — REG.NUMBER 45���Z 0. . Class. C 1F ZF
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCE SED BY
ond Professions Code,and my licensa is in full torce and effed. Power Apporafos&Large Applipnces �
Size&iype HP,KW,KVA,or KVAR �- Q V
license Nomber 45���1 Za_ �;�.ciass- � C44 � Up to 1 Incl. `� FINAL
Amer. SoYar 1-2^«OS Overiro101ncl. DATE �^g_�� VAIIDATION p
Contra�tor Oate Over 10 to 50 Ind. �
OFINAL
I am exampl under Sec. O�er 50 fo 100 Inc. BY :51, �
6.8P.C.for this reaso� Over 100 �I� Z
� Date: Services,Swbd.,MCC&Panel6aards ► �
0-200 Amp.Under G00 V
Signoture 201-100D Amp.Under 600 V
DOvar 1000 Amp.or Over 600 V
Exemplion For Reg.Maint.Elecf.
SINGLE FAMILY Temp.Power Pole 8 Appurtenances '��!,(j,:'��.�
HOME OWNER-BUIL�ER DECLARATION Sign wilh Ona Branch Circuit
I hereby affirm that I am exempt from the CoMroctor's License Additional Sign Branch Circuils *` ° ` ��'
Law far the following reason (SeUion 7031.5, Business and � � �
Professions Code): � �� ,;, �. � p r(�
❑ I,as owner of the properly,will do ihe wark ond�he Mrsc.Condoits 8 Conducto�s � , ��
structure is not iMended or affered for wle (Section O�her(See Complete Fee Schedule)_ , - v �. .. j i� :�..,!
7044,Business and Professions Code).
CON57RUCTION LENDING AGENCY . U �'�"��� ����
I hereby affirm ihat there is a constr�ction(ending ogency for
the performonce of the work for which this permit is issued PERMIT FEE� (Sub-Tolol)
(Set..3097,Civ.C.). � . .
� . PIAN CHECKING FEE . � -
Lender's Nome � .
PERMIT ISSUING FEE
Lender's Address
I certify tbat I hpve read this applicq�ion ond slate�hat 1he TOTAI FEE �
above information is wrracL I agree to comply with all County
ordinances and$tale laws regulating Eledrical wiring,and
hereby aW nze epresentatives of this County ro enrer upon �
16e ab e- enY ne proper forinspecrion purposes.
� � SEE REYERSE FOR EXPIANATORY LANGUAGf
i_ 2-�'
Si�nalu�e of Permiflee Dafe
1+ . . � ��� � ��� ••� � +4 iYb i aes�r�r . �.-
r�� i . _ �.. ��- � _.
13 '�1'r'+� a+s�na �irt Ar�+r�� �� � �... _._ ., , •
.�.-.-.-.��.�.�.� — -- - - —— ' .. s __ . .
. APPROVALS DA7E �� " 01M1`td€R-BUILDER DECLRRATION
S! Tl R ,
TEMP.POYYER POLE I beroby affirm thot i am exempt from th�Contractor's
� . Li[ense Law for ihe following reason (Sectlon 703i.5,
UNDERSLAB WORK Bus7n�st and Profe.slons CodeJ:Anyclty or muniy which
. - ROUGkI CONDUIT � reqt/fres a permR to tons}ruct,aher,7mprove,demollsh,
� or�epotr any slrutfure,prior io Ihs issuartce, efso re-
. WlRING quirsa/iroappllcantforsushpormiitof7leustgnedsfote- -
FIXTURES ment}Rof he is licetned pursuonf ta}he provlsions of the
. . . Coniracfori Gcensa Law(Chopfer 9(commencing wltb
, � POWER AUTHORIZED Sectlon 7000)oi Dlvtslon 3 d the&usiness and Profes-
sions Code)w iFat he is exempi therefrom ond ihe basis
UTIUTY CO.NOTIFIED (or /he ollsgsd exemptlan. Any violation of Section
FINAL �' � 70.3).5 by any appllcanl for o psrmlt su6(etts the appli-
nfer on ronl cont to a civi!penaf}y of not more fhon five bundred
� NOTES . � do�Idrs(S600f.:
� -, � .. - , � ` ❑I,ac owner of tha property will do ihe work,ond
the structure ts not intended or offered for sale.
' � � � .(Sac.704d,Buslrtess artd Prolessions Code: 7he Corztrar
ror's Llronse Low does rrof apply to on owner of property .
� , .� who bulfds or Improves tbereon, and who does such
- work 6fmself provlded thaf suth Improvements are no�
' � inTendod or offered ior sale.If,however,fhe bullding or
improvemwnt is so(d wifhin ono year ot compleNon,fhu
,,� � . ownor•bullder wll!have the bu�den of proving fbo�he did
� nnt bvlfd or fmprove for!he purpose ot sale.)
I am exempt u�der Sec. ,
. . . . B&P.C.for this reason
Date
Owner
