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WORKERS'COMPENSATION DECLARATION 76A663 ioiei APPLICATION �FOR ELECTRICAL PERMIT �
I hereby affirm ihat 1 have a certificote of consent lo self CE-806G
+nsure,or 6,cenifimte of Workers'Compensation Insurance, COUNTY OF LO$ANGELES BUILDING AND$AFETY
or a certified copy thereof(Sec.3600,Lab.C.)
�Cy No.�$�]�Company I�iA FOR APPIICANT TO FILL IN JO
Certi4ied topy is hereby furnished. New Residential Bldgs.8 Vooi4O9 S EACH NO. $ FEE AD RES Ot�'3' 77 AI711�t08 Place
� Certified copy is filed wi�h the county building inspec- 1&2-Family,Sq.N. � p`��TY TR�42586 d �dr
tion deportment. Multi-family Sq.Ft NEA
Residentiol Swimmin Poals CROSS 5.
Da�a 8120/86 Applicanf��T�� �Gee Electric 9 OWNEROR
FIRM NAME Anden Gr .
CERTIFICATE OF EXEMPTION FROM WORKERS �MAII
COMPENSATION INSURANCE ����ets:Rec_light_Sw._ ADORESS 4 P rk View Dr.
(This�uTion n�ad not b�complo}ed if 1he work Involv�d 6y First 20 . CITY 967-9541
th�pormfl is for on�hundrod dollars(5100)or less.) Total No. Add��ional Covina, Cd. 1e1.No.
I certify that in the performance of the work for which this nPI�NCC�HNETCK
permii is issued,I sholl not employ any person in any manner
so as to become subject to the Workers'Compensation laws. lighting Fixtures first 20 ApDRESS
Tmol No. � Additional
CITV Tel.No.
/'�`�� ApplimN Fixed Appliances Not Over 1 HP peRMii
.ICE TO APPLICANT: If, ofter moking ihis Cerfifitate of APPLICANT ��T�� McGeeElectric
Exemp�ian, you should become subject to the Workers' Range_Hea�er_D.W._.
Compensation provisions of the Labor Coda,you must fartb- Oven �Oryer _W.M.� ADDRESS I7�Q� $pX ]_],1], '
with comply "fh suth provis�ons or Ihis permif shall be Top _fAU �_W.H:— CITY
deemed revoked. CII�110 41708 Te�.No. 591-6461
LICENSEO CONiRACTORS DECIARATION Hood _Fan _pther�
Disp. _Room Alr Cond. — UCENSE OR
I hereby affirm ihat I am licensed under provisions of Chapter 9 REG.NUMBER 490083 Clps�i-1� r
(commencing with Section 7000J of Division 3 of fhe B�siness DISTRICT NO. PROCESSED BY LL
and Professions Code,and my li[ense is in full force and effact. Power Apparafus 8 Lprge Appliances �.� U
C�iQ Size&Type HP,KW,KVA,or ICVAR
license Number 490083 ���,Class Up to I IncL FINAL �
Electrical 8/20/86 ove,i ro 101nc1. �AT� �/5^ �� YALIDATION �
Controctor ��e Over 10 ro 50 Ind.
❑ FINAL _—,n � W�
I om exempt under Sec. Ove�50 to 100 Ino BY �/��„r,,, N
8.8P.C.for this reason Over 100 Z
ppte. Services,Swbd.,MCC&Panelboards � �
0-Y00 Amp.Under h00 V
Signa�ure 201-1000 Amp.Under 600 V
❑ Ovar 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Eled. `1 �8 3 A
,�'"'^. SINGLE FAMILY Temp.Power Pole&Appurte�antts
HOME OWNER-BUILDER DECLARA710N Sign with One Branch Circuit �;!e. u . ♦`�
I hereby affirm ihat I am exemp�from ihe Contrador's Litense qddilional Sign Brpnch Circuirs
Law ior the followin9 reoson(Sec�ion 7031.5,Business ond � +a 6 6.8 6
Professions Code):
❑ I,as owner of�he p�oper�y,will do the work and�he Misc.Conduits&Conduciors • n, v�,E�&��
siructure is no�inlended or offered far saie (Sec�ion Other(Sae Complete Fee ScheduleJ._ �
704a,Bosiness and Professions Code). �F L�-8 6
CONSTRUCiION LENQING AGENCY
I hereby affirm Ihol Ihere is a construction lending agency for
the performance of�he work for which this permit is issued PERMIT fEE ($u6-Totol) 56. 6
(Sec.3097,Civ.C.).
PLAN CHECKING fEE
Lender's Name
PERMIT ISSUING FEE �O. O
Lender's Address -
I certify thot I hdve reod ihis opplico�ion ond sta�e thp�ihe TOTAL FEE 66.8f7
above informotion is corred.I agree lo comply with oll County
ordinances and Slole laws regulo�ing Eledrical wiring,and
hereby outhorize representa�ives of this Caunly to enter upon
�he a ove-mention d propery{or inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� � �, $�20�86
Signature of Permi tee Da1e
_
�,t r . . � • ,� ' i' u � � � �
. -
as°k' VrAtS.�,v DA7E� ��'�"" - - O�lch1ER-BUELOER pECLARATIdN.
.. . .:. . 51GNe1TURE . . . �_ ._. .
7 k?.pp l-R FOLE .i � � �+o�'flby atfirm that I om exemp+from Ihe Coniractq.'s
�� - � �� �-�--�- � . .� - Licer.sa law 'For fhe 4o�lawing reasun (Section 7031.5.
�JNDER5:.116 V�GR'�. vV�_. __ � $usMess and Professions Code):Any clty or county wR/ch
' RQUG�#C7t>bUi7� ,- � - . _._cequtre,s a permlP fo cansfrutt,ulter,ImpYove;;d¢moBsh,
� .�._�.,._ --7 t 'nr rep�lr any struct�re,prior to Ms�issUarice; olso re�
� V1lRfntG� � ��p�Y�Q /���,�., qu[res i9se oppltcaat/or auch permlf to ffie a stgned srara-
. . � ������5�� ,-, . �� � mr:nt thct he fs lfcartsadpursvonf to f6v provisiana of fhe
Condracler's litense low(Chaptar 9(cwnmenUng wltb
��� �y�� ��—v..�m � Seciton ifJOf of Divislon 3 ofi the 8usiness and Protes-
!Gt�WER AU7HOFz•.�eG ; � . .. �
� ----- - st�ans Code)or thaf be is exempt fberofrom and.+he 6osLs
�UTiLiTY CO.NqTIFiEL� for l.he allr�ged axemption. Any Nolctlon o1 Section
_ F�NFi �_ cp ! �C31.5 by cny ap�lteanf for a perm7f sub(ecis the appli-
��:lar ott _Yror_f con!fo o dv6 ponolfy of no1 mora than ftve hundred
NO7FS doUars($SOC).: —
� � ' ❑I,cs owner af the praperty witl do ihe work, d
_�,. � _ �____._�, the struct•�re is not intended w offered for sale.
. (Sse.:Od!,Busfnass cnd Professlons Gode: Tbe Conirac-
�� � �- �- � � ,__� tor's[lcmnx�Low daes not apply to on owner of properfy
� � �- � •�� . .... , .._ .. . who bwltis or'tmproves thoreon, and wAo do�s sucb
__.._. ____ � __. ______ wark 6lmseN provtde�lhat sutfi fmprovemsMs are nof
�- ' ' � - tn�ended orOffersd�for saie.H,howeven the bulfding or
^___ _ ___ _ improv�ment is sold withln one year of complefi0n,ihe
. : . � owner-butlder wNl have�he burdan of provtng that he did
,,,,_��._, _,_.. not Eutld or improve�ar the.purpose o!eafe.)
___� ----�---` ---- �pm'ax�i»pt under Sec:_
._ .._..._.___.,._._..._._.�.._._....._.._____._._.-____--_- H&P.C.for fhis reoson
..—. _... __... __"._�__..� .... � Da`e
.____- .__--- —�.—�.----.....__._____�___._. _ �wtter _