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WORKERS'COMPENSATION DECLARATION �6A653 �o�e� APPLICATION �FOR ELECTRICAL PERMIT �j
I hereby affirm thaf I hove a certificate of mnsent to self CE-806G
insure,or a certificate of Workers'Compensation Insurance, COUNTY OF lOS ANGELES BUILDING AND SAFETY ��
or a certified copy thereof(Sec.3800,La6.C.)
a�YN�25859571comPa„Y I�A PORAPPLICANTTOfILIIN ��6
Certified co is hereb furnished. EACH NO. FEE ADDR
py Y New Residentiol Bldgs.8 Pools
� 1 8 2-Famil q. i 4no 5 _ s �oc iTr TR�i425 ia Bar
Certified copy is filed wi�h�he county 6uilding inspac- y,5 Ft.
tion department. MoNi-family Sq.Ft. NEARE
CRO55 5T.
$�2Q�$(� ��T�� McGee Electri Residential Swimming Pools OWNER OR
Dote Appli[ant F�RM NAME Anden Gr .
CERTIFICATE OF EXEMPTION fROM WORKER$' Outlets:Rec_Light_Sw._ ODRE55 1074 Park View Dr.
� COMPENSATION INSURANCE Firit 20
(Thls�ecfion n�od no�ho complelad I!the work involvod by 7otal No. Additional CITY Covina, Ca. r�i.No.967-9514
ths parmh is for ona hundr�d dollon(5100)or lass.) PIAN CHECK
I certiFy that in ihe perfwmance of Ihe work for which this APFUCANT
permil is issued,I sholl not amploy any person in any mpnner
so os to become subject to the Workets'Compensotion Laws. Lighting Fixtures First 20 ADDRESS
Additional
iotal No. CITV Tel.No.
�� Applicant Fixed Appliances Not Over 1 HP PERMiT
f� .+CE TO AFPIICANT: If, after making �his Certificate of APPUCAN7 t�'r° McGee Electric. Inc.
Exemption, you should become subject lo the Workars' Range_Heater_D.W._
Compensation provisions of the Labor Code,you must forth- Oven _Oryer _W.M.— ADDRESS p Q. BOX 1�.�.�.
with comply with such provisions or fhis permit sholl be Top _FAU —W.H,_
deemed�evoked. CITV O 1 08 Ta�.Ng41-6461
Hood _Fan _Ofher—
�ICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensad under pravisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER 44��$3 Class.(�'^1Q �
(commencing wilh Sec�ion 7000)of Division 3 of the Business DISTRICT NO. PROCESSED BY
ond Professions Code,and my licsnse is in full force and effec�. Power Apparatus&large Appliances � U
Size 8 Type HP,KW,KVA,or KVAR ��
License Number 490083 Lic Class C'-1'Q Up to 1 Ind. F�NP`� n O
Over 1 to 10 Incl. �A� '�' � �` VA IDATION �
Conirocror Electrical pa�e g�Z��ab Over 10 to 501nc1. U
❑ FINAL W
I am ezempt under Sec. Over SO to 100 Inc. BY �
N
B.BP.C.for this reason Over 100 Z
Date: Se�vices,Swbd.,MCC$Panelboards ►
0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
❑ Over 1000 Amp,or Over 500 V
Exemptian for Reg.Maim.Elect.
;"'� SINGIE FAMILV Temp.Powar Pole 8 Appurtanances
HOME OWNER-BUILDER DECIARAiION $ign with One Branch Circuit �� 3�'.b a
I hereby affirm that I om eaempt from�he Conirocror's ticense Addi�ionol Sign Branch Circul�s �•�' � • •2
Low for the following reason(SeUion 7031.5,Business and
Professions Code): 1�4 b 6,8 6
� � Misc.Conduits 8 Conducrors
1,os owner of iha property, 'll do the work and the Other See Com lele Fee Schedule
siruUure is not intended or offered for sale ($ection ( p �— , °s °�J 6��6 v
7044,Business and Professions Code).
O�i 28--86
CONSTRUQION tENDING AGENCY .
I here6y affirm tho�there is a construction lending agency for
ihe performance of the work for which ihis permil is issued PERMIT FEE (Sub-Total)
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
Lender's Nome
PERMIT ISSUING FEE IO SO .
Lende�s Address �
t certify that I have read thrs applimtion and state that ihe TOTAI FEE 66.86
above informotion is mrrecY.I ogree to comply with oll Counly
ordinances ond S�ate lows regulating Elactrical wirinq, pnd
hereby authorize representatives of this County to enter upon
the ove-mention pioperty for�nspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
� $�20�86
Signoture of Per itfee Da�e
,+�•� 3 , r� •� .�� i + ! � �� ��t� ��j .��,�
. �r• , : •r ra : , a. e � . . .
' age�,�✓AL5 E�elTE '� 'OWNER-BUILDER��GLARA7�ON-
S!GN.AR��E �
.�... .. �J1�LL PCViF�'Pp1:.�.� i_.W��v�. ! hernby aifirm that I am xxempt trom �he Cantractor's
• �� � � � �=-;-------�—� ,. � , License Law for the following reason (Section 7d31.S.
U'VL�E25LA N,}�K - ' 8us�ness artd Proless�rrns Code):Anyclty or county whlch
____...�__...�...T_.._._.....�,_.�_.., „Saqu(res a crmif io consiruN,aNer,•jmprove,'d¢molish,
RDU F C^vP:CUiT � - - -..... - . P , .
'o'r repvtr Bny s&ueture, prior ta ifs�lssudnce, afso re-
w R�ti� _ ��R t'Y'��'`�rr" ^�..: . . 4ufres the appttcar,t far auEh psrm/t fo fl!e a slqned sfole��
.r_.•., -- � ._
•�—, � mcnt thW H�t Is Jlcansed pursuonY fo 1Me provts(orts ol fha
.'�� �Ik�tJR�S . � Contra<tor's 1PCens�Law(CMopter 9(commencing w7lh
:�:: ....... �_.'—.--.--.._. - -.
�L�- � � �'�� Secitort�7CC0 ot Dtvtstun 3 of TMe Baslnass ond Profes-
- . ;PGINEk AL'TN(�Ri'zL7 � � )
s�ons CodaJ or�hai he�s exempt�herefrom ond tha basis
U71!fTYCO�NJ7i�s��mm /or ihe atieged axempl�o». Any v7olotion of SaN�on
F.TM�, r �} ' 7631.5 by cny appltcan!far a pormlt aubjecfs Ihe oppJi-
_T __C,.n�cr o:v �3renf , ca»t to a clvt(pcnalty af not more fhon live hundrad
'Jd'fF5 da!(ars(SStlO).: �
❑I,as owr.�of ihe property wil i do the waw...id
� _ - ..,_.� ,..,._� _ � � inm structvre is net intenced or affered for sale.
. , . . (Sea 70#4,$usiness and Fro(essiorssCode: 7ha Controa
_._. --- -- � �.____ ' _,__ _ tor's Ltcensa Law does nof appl y fo an ownsr of properry
, _ _ , , � who bultc's or'fmprovas ifreraon, cnd wha does ruch
� __ . work h/msedf proved+�d ihat suchJmprovements cre no�
.....__ _...___ , -.-----�.- tntendsd or of?erod fnr sole.17,fiowever,the buf(ding or
, ,_...� �_i �Y_-__ _�_ ,�-�. �rmprwement is so(d w�thin one yeor of compf�fion,1hv
. . ownar-bullder wid tseve ibe bnrden of proving Ihoi he did
__., ' ___,�.._ _.� nni buttd or Irnprovs for}h��pu�pase of sale.)
.�.___..._�__,__�.�m`___.._,._� . I am-exemri under Set...l._..,.. ,. , ,
�� ._..� _ _�._�.`._...._�_�..�...___...__._ B S P.C,for shis roason� .
- -- ----- _.—.__ .___ __.- � � Qate� _,__
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Owner� ,__, _�