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WORKERS'COMPENSATION DECLARATION 76A663 ,o�a, ppp��CATION F�R ELECTRICAL PERMIT �J -
I hereby affirm thot I hove a certifica7e of consent to self CE-806G
insure,or a certifimte of Workers'Compensation Insurance, COUNTY OF LQS ANGELES BUIL�ING AND SAFETY L4
or a certifi copy f rea4(Sec 3800, b.C.)
���` _�3 � � FOR AMLICAM TO FLL�N JOB
P❑olicy No. Company � � �
Certified copy is hereby furnished. New Res�dential Bldgs.8 Pools EaCH h'O. pEe AODRESS - S�o�a� .z.i F=.�c+�n�e
� 1&2-Fpmil LOCALITY �
Cerfified copy is 4iled wifh the coonty building inspao Y�59�F�� `��� a — � �- �_'a-�'��''� '�'�
tion deportmenl. Multi-family Sq.FY. — NEARfST
CRO$$$i, y �/ �ci 4 �/�`/,
Resideniiat Swimming Fools OWNER OR
Date Appli<ont ' fIRM NAMf /t �i�G-
CERTIFICATE OF EXEMPTION FROM WORKER$' OvNets:Rec� 3 � � h�nil
COMPENSATION INSURANCE noca�SS �" e,.� ,�„ .
This s�ction nwd nof b�com Frf�d if fM work invo7wd 6 ^ �.s1 20
� P y Total No. `' Addi I qTY iel.No.
Th�pirmif Is For om hundred dallon(fi00)or lasf.)
I certify thm in the performanca of the work for which this qpp�ICpNTK
permil is issued,I shall not employ ariy person in any monner
so as to become subject to ihe Workers'Compensotion Lows. Lighting Fiztures Firsl ADDRE55
Tatal No. A itionol CIiY Tal.No.
Date Applicam Fixed Applianc Not Ov 1 HP PERMiT
NOTICE TO APPLICANT: If, otter making Ihis Certifimte of • / APPLiCANT�R-� ���� �- S'O�
Exemptian, you should bemme subject to the Workers' Range_Heat D.W._
Compensation provisions of Ihe Labor Code,you mus'forth- Oven �Dryer W,M._ ADDRE55�3 7,��p �� l+�✓,L
with comply 'th such pravisions or �his permit sholl be Top _p .j_
deemed revoked. Hood ❑n �Othe CITY������6� �„�Tel.No.
LICENSED CONTRACTORS DECLARATION IiCENSE OR
I here6y affirm that I am licensed under provisions of Chapter 9 Disp. Room Air Cond. — REG.NUMB .+�'�T � �� Clas��
(mmmencing with Secfion 7000)of Division 3 of ihe Bosiness Power Apparalus 8 large Applianres DISTRICT NO. PROCESSED BY r
ond Professions Code,and my license is in full force ond af£ecl. y
Size&Type HP,KW,KVA,or KVAR� Q �e..i �
License Numberp����' �� Lic.Class�`/ Up to 1 Ind. V
/ '�Cy�� RNAL
Coniracro��/`r���l"��8�e c:S f � Over 1 to 10 Ind. DATE ._f/�.�f- �':J YALIDATfON O
Over lO to SO lnd. FWAL V
❑ I om ezempt under Sec Over 50 l0 100 Inc. BV.-�- � 4 1 W
6.8P.C.for ihis reason Over 100 � �':'3��"�.. �.. - � �
Services,Swbd.,MCC 8 Panelboords � -
0-200 Amp.Under 60D V
S�nnnr .P_� -�� 201-1000 Amp.Under 600 V
❑ Over 1000 Amp.or Over 60m V
Exemp�ion for Reg.MaiM.Elect.
SiNGLE FAMILY Temp.Power Pole&Appurtenances <1 J G 1�'�
HOME OWNER-BUILDER DECLARATION Sign wirh One&anch Circuil
I hereby affirm that I am exempt from the Controctor's License Additional Sign Branch Circoits ":R� `' ° e •?
Law for the following reason (Secfion 7031.5,Business and
Professions Code}: � c c Q� �p
� Misc Conduits 8 Conductors 4 .
I,os owner of the property,w�ll do the wcrk and ihe f , � �'�
slruUure is not iniended or offered for sale(Secfion Other(See Complete Fee$chedule)_ � � . i�./'J c
7044,B�siness and Professions Code�. R [i 'j,?,� _,c�r
CONSTRUCTION LENDING AGENCY .
I hereby offirm that there is a mnstruction lending agency for
the performance of the work for which this permit is issued pERMiT FEE (Sub-Total) 1
(Sec.3097,Civ.C.j.
PLAiJ CHECI4ING FEE
Lender's Name
.PERMIT ISSUING FEE �� �G�
Lender's Address
I certify iha�I have reod this applicotion ond state that the TOTAL FEE � ��r^
obove info�mation is correct.I agree to wmply with all County
ordinoncas ond State lows regulo�ing Electrical wiring, ond
hereby authorize representalives of ihis County to enter upon
1he ove-mentioned p operiy f inspection p poses.
n SEE REYERSE FOR ElIPLANATORY IANGUAGE
� d
Signature of rminee Dar. .
kt>PIFDVALS pqie ��— O�VN€R-6UILpE�D�CLARATION
°"('=A'y1TURF
T�p,ppy�.p pp�E � i hcre�y afflrm thcr I am cxcmp�ficm thc Contracra.'s
Licensa lcw fn� tho following rccscn (Sr,ction 703L5,
UNDERSLAO WORY. Gusincss and Pro?e;sions Cod:):Any clty or county w6/ch
ROUGH COhDUiT rsqutrc;o p�rmil to mr,frud,clicr,Improvc,d_mofish,
ar rcpatr eny slrudurc,prlor to Rs issvanc<�, also rr
WIRWG � � quiresifiecppl(car,:forsvchpermittofilcasf^rtcdstate-
en�that h�Is I�c.:nrsdpursuani fo fFe provi:ions of the
FIXTUR[S Contractor's Llcr.n:e Lcw(Chaptrr 9(commr.ncing with
POWER AUTHORIZED � Seciiorr 70fi6)of D;N.te�3 a the 6usino-,and I'rofes-
sions CodaJ o:that he L-exc,rnpt fhe-^from and the br.,is
UTIUTY CO.R10TIPI� lor fhe a!lsged oxo-mptian. Any violc:icn ol Scc�ion
FiNhL ���K anr 74�1.5 byr onyr nppliean�t fer c permlt wbjsHe ihe oppli-
------�----- f9H�10 6 LivII�et{��r o!not mnre thcn fivc hundred
. NE7PE� delfora(Sb6E1J.:
� . ❑I,os ewnrr of tha prafetrty will cb the wwl.;and
the strueture is not iniended or offercd for salo.
(Sx.7Df4,Eusirtses and Pro£oss'rcns Ccder 7ha Cantrac
_ _ for's Lleense Low de ss nst ap{�y in a.�c�.wnor o,'pro�erlY
wFo baila's cr i,r,�roves Ihareon, and who c!oas such
_ _.____ ___'__. work Vrimxi�peoriabd ihw wch irr.�rov.�eenf>cre not
iMandrAor e{ferc�for scals.I',hewever,the E-uilcNng or
_ r,�.,ro.�e,wer,r rs se,�d w-rthrn�na y�af com�.lar;an,rh�A
ownr-(Ktffdw x•i1 i hev�ihe hurden cf provin�thcY h.r,dId
nef 6ertd cK impravw lar tHe purprsae of sale,J
_. ___ I am cxempt unde;$ec, _ ,
-- 6&P.C.for ihis reason
--. ._._— --- �
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