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WORKERS'COMPENSATION DECLARATION �aA�3 �o,e� APPUCATION fOR ELECTRICAL PERMIT �
I hereby offlrm Ihm I have a certificare of co�sent to self CE-806G
insu�e,or a certifimte of Workers'Compensaeon�nsurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof(Sec.3800,Lab.C.)
a�Y N�q2585457 ]Eompany I� FOR RPPLICANT TO FfLL IN JOB
Cerfified copy is hereby furnished. New Residenfiol Bldgs.&Pools EACH NO. fEE AD ESS
f'1 � 1 82-Famil Ft.����•_ & — a LO ALITY
LS Ceriified copy is filed with the county building inspec- Y.S9� _
fion department. Multi-fomily Sq.Ft. EA ST
CROS �Jb,
Date 8�2��86 Appiicant "T" McGee Electric Residenfial Swimming Pools OWNER OR � en Gr .
FIRM NAME P
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._ '�'A��
COMPENSATIONINSURANCE ADORe55 107G-Park View IJI.
This aection n�ed nm 6a com lel�d if th�work involv�d b F��S��
( P Y Total No. Additional CIiY Tel.No. _ 41
1he parmit is For one hundred dollars(5100)or lecc.) PtnN CHeCK
I certify ihat in the performance of ihe work for whith ihis APPLIGANT
parmif is issued,I shall nof employ any person in any manner
so as to become svbjatl to ihe Workers'Compensotion Laws. Lighring Fixtures First 20 ADDRE55
Addilional
�... � Total No. GITV Tel.No.
aPP����^� Fixed Appliances Not Over 1 HP PERMIT
h.,��CE TO APPLICANT: If, after making this Certificate Of • APPLICANT ��T�� McGee Electric, IIIC.
Exemption, you should betome subietl ta ihe Workers' Range_Heater_D.W.—
Compensaiion provisions of tha Lobor Code,you must forth- Oven _Oryer _W.M._ A�DRE55 P_fl_ $QX 1111
with comp�y with soch provisions or this permit sholl be Top _FAU —W.H.— CITY �j,IIO 9�.��8 Tei.rio.591-6461
deemed revoked. Hood _Fan _Other_
L�CENSED CONTRACTORS DECIARATION � uCeNSE OR
i hereby affirm that I am licensed under provisio�s of Chapter 9 Disp. _Room Air Cond. — REG.NUMBEe 490083 ClassC-l.d }
(commencing wifh Sedion 7000)of Division 3 of rhe Businass DISTRICT NO. PROCESSED BY �'
and Professions Code,and my licanse is in full force ond affect. Power Apporatus 6 Large Appliances . U�
Size 8 Type HP,KW,KVA,or KVAR� �a
440083 C-10 �
License Number Lic Class Up to 1 Incl. FINAL
Electrical Over 1�0 10 Incl. DATE ;�,���-e,r-�� VA IDATION �
Conhactor Dafe 8�Z��8� � �
OOver 10 to 50 Incl. fINAI �+1
I om exempr onder Sec. Over 50 Io 100 Inc. BY �,����' 2<<. a
B.&P,C.for ih�s reason
o�e,,ao � �c�r� z
Da�e: Services,Swbd.,MCG 8 Panelboards �
0-200 Amp.Under 600 V
Signoture ' 201-1000 Amp.Under 600 V �
❑ Over 1000 Amp.or Over 600 V .�_� v�'�A
Exemplion for Reg.Maint.Elect.
�' SINGLE FAMILY • • •
� HOME OWNER-BUIIDER DECLARATION Temp.Power Pole&Appurtenances #• •2
Sign wi�h One 8ranch Circuit
I here6y affirm tha�I am exempt from the Coniroctor's License Additional$ign Bronch Circuih � � 'O'�6�0 6
Low for ihe fotlowing reason (Section 7031.5,Business and �
Professions Code): ^ «��F�h��[i�:u
❑ I,os owner of the property,will do the work ond 1he Misc.Conduits 8 Condoctors
structure is not in�ended or offered for wle(Sec�ian Other(See Complere Fee Schedule)_ , p�-2 E"�',b
704d,Business and Professions Code).
, CONSTRUCTION LENDING AGENCY
. I here6y affirm�hat there is a construction lending ogency for
the performanca of the work for which this permit is issued pERMIT FEE (Sub-Total) .
(Sec.3097,Civ.C.).
PLAN CHECKING fEE
Lender's Nome
PERMIT�SSUING FEE ZO SO
Lender's Address
I certlfy thot I hove read this applimtion and smte thot�he TOTAL FEE 63.�
above information is correct.I agree to comply wifh all Couniy
ordinances and State laws regulaling Electrical wiring, and
hereby aulhorize represenfatives o4 this County to ente�opon
the ob ve-mentione ,property fo�inspection purposes.
S�ZOI86 SEE REVERSE FOR EXPLANATORY IANGUAGE
Signature of Permittee Dote �
� i �ti� . �. ii . , ' i , � �i • ; }i�S�' i11� _���
p.F��.C+VAiS DATE �v���� ���� �� QSNN�R-BUILDER DECIRRP,TiOh1�
. . � . —�L.__._. 5lC�1ATU� . .
��AF.POW:R FQ;z��_ � I her�by nffim�'hat 1 am exempt from 7he Controcto*'s
� , . _ � , . L conse law for thQ fuilowing f905U�'�SBfflpfl 7031,5,
' UND`r.�S�F.n v`tORK f `" " �_ � .0 fness andProf_sslons CodeJ Any cfty or rourtty whlcb
ROEtGH C�PJ�;11T . .requ(r�s aPgfml!to mnstruet,al�er,'mpneve,demoifsh,
, � , � .� �-� ��� �or r2pvtr ony siruNure,prior io 71s issuanca. alsa re�
4N R1NG �pI�/E/,� �f/�j . quFres the a p plicc»f fo:suth parm7t io f!!e n sl gned siate-
,�. -" -.��"': -F�x,��6r ,f � ��"7"f '" mentlhas6els!lcansedpursuanttotheprov�sionsotlhe
- _�_�_�. Cont.-nrtcri Cicsnse Law(Chapter 9(commenUng w�ib
�� � Sac�ion 700G o{DNtstan 3 of the Business and Profars-
-' . . - POl'Y@�AU(NG�Ft`Z.ED )
f -- � zians Cods)of fFia�he is axemp�fherafrom and�Ae basis
'U7:117Y CL',ri<JTIr�lED �_ /or thn aN:agFd ezempfion. Any vtolation of Sat�on
�. FINAL .0 �4 7C31.5 bp any npp!ltur.i for a permit xubjec7s tha apph-
_.�._ , C,,n{er pn _�ror'-f carst fa a dv(I penal7y of nol more}ynn five 6unrfred
w6rEs dol(ars($500),:
. . . � ❑I,as owner of th�property will�dc ihe wark,�nd
_ ' �� ._,,.,_,,.,,'.,,...,___._,�._ _ ihe atructure is not intenu�ad or offered far sale.
(Sec.7th4�,Bus'rnessondProfess7ortsCode� TheCon�ror
' -�- � '- ' ' ____ fot'x lleenso Cow does nof opply�o an owner o/properfy �
- � -� � . � - � � ���� who 6ut7ds or'tmproves thareon, and who does socb
r�sork btmsel!providsd dhat such�'rmprovements are nof
�'`� � � � � �rroe�ded ag afFerad(or sofv.N,however,�he buJlding or
`_ . �,_ ___�___._„� bnprovemsM is sold vrttbin one year of oompleHon,ihe
- � . . owner•bvllder wtlf have tbe burders of p;ovtng that he did
_____ `_ � not Eafitd or(rnprove for ihe purpaso af sale.)
_____�, _ I am exempi under 5ec. ,
-- ------- --- .�..,._._. _____ _. . B&R.C.for this rer,son � .
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