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WORKERS'COMPENSATION DECLARATION 76Al� �o,a, ppp��CATION FOR ELECTRICAL PERMIT �
I hereby affirm that I have a certifiwle of consent to self Ce-e�6G
insore,o�a serrificate of wo�ke�s'Compenwron�nsurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or d certified copy thereof(Sec.3800,Lab.C.)
O�y No.G25859577�ompony 1� FOR APPUGNT TO FIIL IN �OB
Certified copy is hereby fumished. New Residential Bldgs.8 Pools EACH NO. FEE �+DD 5
_ � Certified mpy is filed wilh Ihe munty building inspeo 1&2-Family,Sq.R. ���6� a = 3 �OC L�TY TR�f42586 j.3. B3L.
�ion deparfinent. Muhi-family Sq.Pt. NEAR
Residentipl Swimmin Pools CRO555.
oaie S/20/86 qPP�i�a�j�T�� McGee Electric 9 OWNEROR
FIRM NAME Anden Gr .
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec__Light__Sw.__ '�'��
COMPENSATION INSURANCE ADDRE55 1074 Park View D.L
Thi�saclion na�d no�be com IN�d if th�work Involv�d b Firs1 20
( P Y Total No. Addi�ional CITY COY3II8 C8. T�i.N�.g67-9541
tho permif t:for one hundr�d dolfan(5100)or le�s.) PIAN CHECK
I certify thal in ihe performance of�he wark for which Ihis APPLICANT
permit is issued,I sholl not employ any person in any monner
so as to become subject to the Workers'Compensation Lows. Lighting Fiztores First 20 A�DRESS
To�al No. Additional
�� Applitant CI7Y _ Tel.No,
' .GE TO APPUCANT: If, afler mokin this Cer�ificate of Fixed Appliances Nol Over 1 HP � PERMIT n u
9 Ran e_Heater�D.W._ AppucANT T MeGee Electric, IItC.
Exemp�ion, you shoald become subjetl �o the Workers' 9 ---
Compensotion provisions of the Labor Code,you musr for�h- Oven _Dryer _W.M._ ADDRESS p,Q. $OX 1111
wilh mmply with such provisions or this�permit sholl 6e Top _FAU —W.H.—
deemed revoked. Hood _Fon �Ofher_ ' CITY ChiAO 91�0$ rei.No. 591-6461
LICENSED CONTRACTORS DECLARATION IICENSE OR
I heraby affirm that�pm licensed under provisions of Chopter 9 Disp. _Room Air Cond. _ REG.NUMBER Clpss .� Q }
.(commencing with Section 7000)of Division 3 of the Business power Apporatus 8 Large Applipntes DISTRICT NO. PROCESSED&Y fL
ond Professions Code,and my license is in full force and effect. U
&90Q83 Size&Type HP,KW,KVA,or KVAR ��
License Num6er Lic.Class C�1� Up to 1 Ind. FINAL �
Over t to 10 Ind. DATE /J,/C�/�'� �
Confracbr F.leCtr�Ca7 Da1e 8�a�? VAUGATION U
❑ Over 10 to 50 Incl. FINAL � W
I am exempt under Sec. Over 50 l0 100 InG BY a
B.&P.C.for this reason Over 100 �`afsta��� Z
pa�e; Services,Swbd.,MCC&Panelboards ►
0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
� Ovar 1000 Amp.or Over 60p V
Exemplion for Reg.Moint Elecf.
,�""" SINGLE PAMILY Temp.Power Pole 8 Appurtenonces .2 1 3 8�7 A
HOME OWNER-BUILDER DECLARATION Sign wNh One Branch CircuH .c e c u s
I hereby affirm fhot I om ezempt from the Conlracior's License �% 2
Low for the following reason(Section 7031.5, 8usiness and Additional Sign Branch Circuits .
Professions Code): ("'�s�7 5�Q 2
� M;sc.Conduits 8 Condutfors W
I,os owner of�he property,will do the wark and the 5 i^�^•_
structure is not iroended or offered for sale(Section O�her(See Comple�e Fee Schedule)_ , `�`�"��'
7044,B�siness and Professions Code). ���&�-�6
CONSTRUCTION LENDING AGENCY
I hereby affirm rhat lhere is a construction lending agency for
the performance of tha work for which this permit is issued PERMIT FEE (Sub-Total) 62 $2
(Sec.3097,Civ.C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE I.O SO
Lender's Address �
I certify that I have read ihis application and state�hat the TOTAL FEE ]�.02
above information is correct.I agree to comply with all CouMy
ordinonces ond Sfate laws regulaling Elecfricol wi�ing, and
hereby a�thorize represeMatives of this County ta enter upon
the p ova-menlio ed proper y for inspedion purpases.
SEE REVERSE fOR EXPLANATORY LANGUAGE
u� s/2o/s6
Signoture o Permittee Da�e
* ��#, YJt �� �' I 'a ��o-1 �F(�;i A]i .�I�
AFCR3VAL5 DATE � � iAWNER-BUILDER p�CLARATION
,.. �: �-- �... �_._..- --- ���GMikTU�E
: ��ER`p FvV F�PUii � I haraby atfirm ihat f nm exempt from 1ho Contrattor's
• • ' � —j--�. - � licenxe Law for �he foltowinp reason (Section 703�.5,
��>.DFRS�AE JJOFK� � � �• �� 6usiness and Professlo s CodeJ:Any ctly or couMy wh:ch
- �UG i C7wJD : � ^ � ' . � � -F,eqvires a pe,rmti fo consiruot olfer,fmpraVe�demolfsh,
_ __�. . __.__ � � �vr regctr any'sirucfure, prior ro Hs IssLarlce,�olso re•
Vli RI'd�,. � ^^� ��� ��-� �/��j gu/res tF,e opot7car.t/or such permlt fo itJe o slgned siate-
,, • . � �.��"" f —� ��"'-��- ma�nF thc!hv is 7iEbnsedpters�Wot to ths provlslons of fR•
. �,,.,�, - „_,� � ,__ Con!ra[tor's Liter,se inw(Chapfer 9(cart;menriwg wlih
a. , . ���,�_��� .��.�_._ � . ._.___ � Saction 70QOj nf Divtslan 3 0!the&usiness dnd Proles�
---�----� �—� s1�n,Coda)crdhai he fs exempt ffrare(rom and!M basis
liTl!{TYCO N'�Ti"tED � far iho ollegecl exempNar.. Any rialetron ol Saction
F���: r cq 7G3l.S by cny applFcan"/or a permif subJects fhe oppli-
� !�}nfva rsn _3'ranf canf Vo a clvil pen�lty oi not more ihan flve hundred
fd07ES doflvrs(55IXJ).: .
, . � . ❑1,as owncr of tho prope>ry wlll do the wor� ,,d
�-��� �-�� -��- � � �.� -�� � "._._, _,,.� the structure is not iMe�ded or offerad for sole.
, ;�` , ,, � , � � (S�c.7tl44,SusJnsss ond Frofesaions Code: 7ho Cantroc
_ . __.� � toi s Llcsnse Low does no#cpp}y to an ownar of propeNy
, __ , , „ • who butfds or',tmp.=oves �fiareon, e�d who dnn aucb
,. .. .. . . � .,. . ;
-� � wa�k 6imse!€provlded thQe such improvements are not
- — ----,..... .__. _�._ _.,.._..
' . . _ . INvndad or oftarad for sate-N,however,Ihe hwidirg or
„ �_ __v__, �____,_,,,� improvcment is so/d within one yanr af cornp(elion,the
_ � ownerv6uilder wfG have the hurden ot provfnglhaf he did
� _.__�_ ,_ � nat l�ufld or improve for tkQ p,rqpose oi sale.)
_._�..� __.`._�__�_ I am�exempi under Sec.� .
.�. �.._..._.._... .�..-.............�...��.._�...._�`..____.... .� B&�F.G.for�his raoson .
_—. ..... .._.-------...__�.—.._....__. __._
Date„_,.._.� .�__,.
--_ _._..._. ....._..� Owr,�rr _....
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