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WORKERS'COMPENSATIONpECLARATION 78A663 APPLICATION FOR ELECTRICAL PERMIT �
CE$OBG(2�801
1 hereby aftirm thet I have a certi£lcate ot consent to se�e COUNTY OF LOS ANGELES BUILDING ANp&AFE7Y
insure,or a�certiticate oi Workers'Compensation Insursnce,or , �
a cer[ified copy thereof(Sec.3800,Lab.C.)
I po�i���,0_.6249�pmp�,�"�morit �*ridemni tv FOR qPPUCANTTO FILL IN DDRE55 _
- - - � New ReSidential B�dgs.&PoOls �ACH NO. - FEE
� Certified copy is hereby furnished. 1&2-Femily,sa.Fc..�667 $ '— $ �ocnurv � �#33645—A Rawland Hei h
� Multi-family Sq.Ft. — NEAREST �
�CArtlfied copy is filed with the county building inspection CROSS ST
departmenL � Residentia�Swimming Poals OWNER OR PT'@5 � �A. . ,
Da[e �+^7^�� FIRM NAME
App]icantnC�� I�fcGee� Electr.ic Outlets:Rec..�Light.LSw._ �MAIL
- � First 20 AOORESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additionai CITY Tsl No.
� CODiPENSATION INSURANCE � - C�SM1�IJOY't �C'1CI7 540-0500 �
� � PLAN CHECK � a
APPLICANT � O
(This seMion need not be completed if the wock involved Lighting Fixtures First 20 AODRESs � V
by the permit is Yox one hundxed dollazs ($100)or lessJ �Additional �
� - Total No._� � . p
I certify that in the erformance of the work for which this CITV 7al No. �
p �ixed Appliances Not Over 1 HP f'
permit is issued,I shall not employ�any person ln eny manner PERMIT W
so as to become subject to the Workers'Compensation Lnws. Range_Heater_D.W,]_, ' APPUCANT��C��- MCGBE EZeCtI'.1C =IIC y
� � Oven _�ryer 1 W.M,_ ADpRESS N
2
Date Applicant Top _FAU },W.H.._ .
Hood_.Fan _Oihar_ CITV Tel No.
NO'IICE TO APPLICANT:If,after making this Certificate of Disp. _Room Air Cond._ 9• oo q G.NVMBER 1533� 8 c�es.
ExempNon, you should become subject to the Warkera' �
Compensation provisiona of the Labor Code,you muat forth- Power APparatus&Large Appliances DISTFiICT NO. PROCESSE�BV
with compty with such provisions or this permit shali be � Size&Type HP,KW,KVA,or KVAR �� ��d
deemed revoked.
� Up to 1 IncL K"y
FINAL
Over t to 10 Incl. oArE �1 VALIDATION
, LICENSED CONTRACTORS DECLARATION Over 10 to 60 Incl. 'I�—O
I herebY affirm that I am licensed under provisionsbf Chapter Over 50 to 104 In0. FINAL �
8Y
� 9 (commencing with Section 9D00)of Division 3 of the Busi- Over 100 �
ness and Professions Code,end my license is in fult force and
effect. , � Services �
License Number 15�3 3 78- �;�.C189S C'�.10� 0-200 Amp.Under 600 V � -
201-1000 Amp.Under 600 V �
co,,,�e�,o� Eledtrical nete �^�^g� Over 7000 Amp.or Over 600 V ��C f��.� {'�
� HOME OWNER-BUILDER DECLARATION 7emp,power Pole&Appurtenances �? o�• t«' u
I hereUy effvm .that I am exempt from the Conttactor's � Sign with One Branch Circuit ( � � ��r�
License Law Por'the following reason(Sectian 7031.5,Busi- Additional Sign Brench Circuits �
ness aod Professions Code): - � °��' � �'d�'�'�'
Misa Conduits&Conductors ��..�L��.�
� I, as owner of the property,will do the work and the Other(See Complete Fee Schedulel— � �
structure is not intended or offered for sale (Section �
7044,Business and Professions Code).--
CONSTRUCTION LENpING AOENCY � - � .
I hereby affirm [hat thete is a Construction lending agency "
tor the performance of the work for which this permit is pERM1T FEE (Su6-Total) H92 � � .
issued(Sec.3097,Civ.CJ.
Lender's Name PLAN CHECKING FEE IOne-Fourth Permit Feel �
Lender's Address pERMIT ISSUING FEE . .
I certify that I have read this application and state that the TOTAL FEE a.00 rJl �
above informetion is correct I agree to comply with all County �
ordinances and State laws regulaHng Electrical wiring, and � �
hereby authorize representatives of this County to enter upon .
the above-mentioned property for inspection purposes. SEE'REVERSE FOR ERPLANATORY I,ANGUAGE
4�1-91
Sig iure of Par ' ee �Date . � �
- � ii'�rlf'�ia� !�!� ii!'liT��ri a. ;�" *a... .�, . � a , : .. �.�....
ON�i£li-BUR.HC�A B�E�iAcR.ATiAti
� � t hr.reby afPRn Fh�t�b am eKmnp6 from ebe Cenlra�Eoe's
� t�.a�Rovn�S DATE �N3� � Fi•� Licen=,;. j,aw for the foDnwirtg reason/Sec�iere Z031.5.
. . __ SICNaTuaE . ...Ausi,�esy�a�rrj�p•ofess+oris CoAPJ: A�y ciry�or county
�� � � � � TEh7P.POwasR PO�e ' - � which requrres q permit !o constrt�cl, alter, improve,
� � �� � � � �� - � � der.:ofisli, or repair m�y structure,prior to its issuance,
� UNOER�LAB WORK
. . a!so requires the ppplicunt for such permit ro fi(e n
� �.FOU�H�co^�oulT � ' � sioncd stctement lhat he is lirense�i,purse�ant ro tke
� � — pmrisions of the Cwitmcror's [,icense Law (Chapter 9
WiRiNG ^ �� -� � . . . ,-/canrnencLig'Iv:7Jr Srction 7000/ of-Dirrsion 3ojthe
� . � ;FIXTURE6� � . , � � - Busrrtess antl Professions Code/ or thar he is exempt
� � -�--�+--� ------ tJ�erefrom and the basis for the al7egeed exemption.Any
. . . .� ...�... . .. vciiaE�nurr�caizeo � � violmron of�`cFrex 7031.5 bY�l'aFPlicantf�ra permit
unurY Co.rvonr-I[o � su6;ecrs th^.oppi3'cont to a cNi!penalty of rror more t!w»
-- .� .((ve ffun�lred do;lws(J�5'ab/.: �
. .. ._ F W�L �.:.:ah a.'t �3�ss� � � � � � ❑I,as ownec of tiie propzrty will do the work,and
� ' tltie stmcture is not iiatended or offeaed foc sale.
; ho?ES . � . /Sec. 70J�4, BusH:ess ortd I4ofesaieres Cod¢: The Corr-
' . ' � . troetor's Lec�nse La-w doas rrot apWy to ar ow�+�r of
, propcny wlia bui7rls or irnproves thereon,ar+d wlro does
. ,. .. �, . � � such wark hr»tcc•If provicled that suck rntprovements
'-- � . are not irt�e+sder!or nfferiaet fe�r sale. If, howe-ver, the
-�- - - � . � ��.. . .. . .. . . . building or irr��rorcrnent tc sald wifhen one year af
. . -,,'— . . corhnletier�, rke owrazr-fiuikler wef! ha>�e the bwder+
. . . .. . . . . . . � of psovrxg ihat Fn- dKl �tot 6w'ki or i�»preve for the �
—. pr:-riese of satc./
� '"---- - � — Iam exempt under Sec. ,
— ----------'— II&P.C.for dzis reasoti
llate
C3xner