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WORKERS'COMPENSATION�ECLARATION ��.�3 io�8� qpp��CATION FOR ELECTRICAL PERMIT. �
I here6y qffirm ihat I have a certificate of consent to self CE-806G
insure,or a.ce�rfcate of wo�ke�s'Compensation Insura�ce, COUNTY OF LOS ANGElES BUILDING AND SAPETY
or a cerrified copy thereof(Sec.3800,La6.C.)
O�y rG,25859571 Company I�A fOR APPLICANT TO FILL IN !08
Certified mpy is hereby furnished. New Residentiol Bldgs.R POi563 EACH NO. �FZ SZ F+DD 55
� Certified copy is filed with the county building inspec- �&2-Fomily,Sq.R. � = S LOC LITY
tion deparlmenf. . MuHi-fomily Sq.FL CROSS 5.
Residenlial Swimming Po0�5 OWNER OR
Date��._A licant �� �T u_r,.., ri....«
PP �—xacvcc—ascc-cL� F�RM NAME
GERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw.__ N'A��
COMPENSATION INSURANCE AODRE55 k View Dr. .
Fint 20
(This s«tion need eot b�compl�fed ff fh�work involv�d by Total No. Additional ��Y�pg Cg. Tel.No.g(yJ-9S4I.
fh�permit ta for one hundred dollmf(SI00}or la�s.) .
PIAN CHECK
I certify that in�ha performance of the work for which this A7PUCAM
permif is issued,I sholl nOf employ ony person in any monner
so as to become su6iact to 1he Workers'Compensalion Laws. Li9Ming Fixtures Firs�20 ADDRESS
lotal No. Additional CITY Tel.No.
�� Applicam Fixed Appliances Not Over 1 HP PERMiT
t. .rCE TO APPL�CANT: If, after making ihis Cartificate of APPUCAM ��T�� McGee Electric, ITIC.
Exempiion, you should become subjed to the Workers' Ronge—Heater_D,W._
Compensotion provisions of the labor Code,you must forih- Oven _Dryer _W.M._ ADDRE55 � 'P�p. $OX 111�.
ith comply with.such provisions or �his parmit shall be Top _FAU _W.H.— —"—"—"' �—
deemed revoked. Haod _Fon _Other_ C�ry ' 9170$ Tel.No. 591-646
UCENSE�CONTRACTORS DECLARATION UCFNSE OR
Disp. _Room Air Cond. — ReG.NUMBER 4 OO$ Closs. C—�.O
(here6y affirm that I am licensed under provisions of Chapter 9 �
�commencin9 with Secuon 7000)of Division 3 of the Business DISTRICT NO. � PROCESSEO BY
ond Professions Code,and my license is in full force and effect. Power Appara�us&large Appliances p
Size 8 Type HP,KW,KVA,or KVAR V
490083 C-10 �
License Number Lia Class U to 1 Ind. FINAI
P DATE n �
Over 1 to 10 Incl. / � ��
Contractor Electiica� Date A�OI96 , VAUDATION
O Ove�10 to 50 Incl. FINAL i � W
I om exem t under Sec. Over 50 to 100 Inc. BY r, .,,�'j'� a
P ��� s fA
B.BP.C.for this reason Over 100 Y Z
Date: Services,Swbd.,MCC 8 Panelboards ,
0•700 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 600 V r"1 3 E.b'A
Ezempiion for Reg.MainL Elect.
t'�' SINGLE FAMILY Temp.Power Pole 8 Apportenances #�" � � ° °2
HOME OWNER-BUIlOER DECLARATION Sign with One Branch Circuif
1 hereby affirm ihot I om ezempt from the Cantroc�or's License Addilional Sign Bronch Circuits � � ��?��
Law for iha following reason(5etlion 7031.5, Business and
Professions Code): � G � �1 J:�I G c=.�
❑ f,as owner of the proper�y,will do the work and the Misc Conduiis&Conducrors
siroc�ure is not intended or offered for sale(SeUion Other(See Complete Fee$cheduleJ_ , ��'���`�b
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm�hat there is o constroction lending agency for �
the performance of�he work for which this permit is issued pERMIT FEE (Su6-Tolal) �2 )r2
(Sec.3097,Civ.C.}.
PLAN CHECKING FEE �
Lender's Nome
� PERMIT ISSUING FEE
Lender's Address
I certify that I have read ihis application and s�ale ihof the TOTAI FEE
above informotion is correct.I agree to comply wi�h oll County
ordinances and Stote laws regulating Electricol wiring,and
hereby authorize representatives of this County to enler upon
the abpve-mentione property for inspection purposes. SEE REVERSE FOR EXFIANATORY LANGUAGE
�.� � � 8/20186
$ignoture of Permif ee Da1e
' ��113'� �� �;w f�H�� ![' � i�UI�A]�J�1 Jk
. �� _.� . _ ,o.. a . � .
n�aaoVa�s pATE ��s ^ OWNCR-BUILDER OECLARqTtOns ,.
. . - � SEGKAFt1Rf
.. .. , � ..� _.- ...._.m.__....
���� �� � � Tr 1('.FQvVtR i i � I hareby offirm tho'I om exempi from 1hQ Contractor's
� � �c—-�-----� -- -'� Lic�rtse Lnw {or the following reason (Section 7031.5.
-' UND SLA3 Y1J,�: I � � Business and Professions Code):Any city or roun,ry whtch
R,J�����.�����.�.�"-�..'m.'..�'. Y'....�i�mm'.�'��� � requires a permit to cdnsiruct,a(fer,improve,demofish,
f ...._�._.. . ...�- � �.qr rMiofr'Wty itructure,prior to)fs tsiNodro,also re-
• �WlR�h!G � J�V. �, ,r�. -�'�,/?. . quires the a�rp7ltnnf forsvch permtf fv fiie a slgnad sta�e-
. ..'-P' � ���- �� mant tha7 he Is ticensed pvrsuonf ta tbe provls(ons of�he
•�` ' ' FfXrJR"c5 �. , �
Confraotor's L1Lense t¢w Ch er 9 comrmensing.wlfh
.. l_..�. �_._1--.-.-�._. � ___ ( �+ {
Section 7Q#ltl of PiWsFon 3 0/!€re Bustness vnd Pro}rs-
� � � - ` . -PO JERAI,TFfG.fZ`CJ . . �
-�------- ---- zions tode)or fhai he is exarnp7 tFsrefrom and tha bosis
U7i!!TY CO.iVOFIF;�� . {or the alleged-exempHan.�Any viclotlort ol Secllon
- FINAL ' � TA?I.5 by any a,cplt�nnf for a permit sub�octs the oppfi-
. _y^_�, �i,t{vr on. �r4nt cont to�a civlt penaNy o(not more than f)vo hundrsd
NOTFS - datiars(3500j.: �
. - � U i,as awner of the properiy will do the wcr�. .td
� _. � __....— � ihe strutture is not intend�d or offered for sale. .
�� � � � � (Sec.�Db4,Busineas ond Professlor.s Cocie: 7he Contrac-
� ' � ' ' to�i L�ceaso Law doas nct opply to an owner o1 preperry
, . , . , . , . . whc butids ar�lmprovas fharfon, ortd who does aucF
- - � �� � __________�„��_ . work htmsetf provida:l thaf such-lmprovements are nof
�—��. -_��� -�,��. - !- .. . . lntertdcrd or of{ared far sa#e.I/,bawouer,ihe bufldiny or
_ ,�__ _ _� �mprwoment ts sofd wiihin one yeor of complenon,Ihe
. � owner-builder wi!(hcve the burden a6p;oving thaf he did
_ � �;net 6�Ifd or lmproro forYhe:purp9ss of sale.J
-------._ �___.,.. __.....__ � � .. i.pm exempt under Sec.
i . '
--- ... .--.--_..- . 6&P.C.for ihis rnoson
..._._ __v_._...__,.._.._.�_._.._ _. - — Date _.____ � .
�_�...._._.._ _..__. ..�._ __.__ ._..�_ Owner --