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WORKERS'CO'v1PENSATIONDECLARATION 76A663 qppIICATION FOR ELECTRICAL PERMIT � �
CE�BO6G(2�801
I hereby affirm that I have a certiticate of consent to sel( COUNTY OF LOS ANGELES BUIIDING ANp SAFETY
iasure,or a certificate of Workers'Compsnsation Insurance,or � �p����� ���
, a certified copy thereof(Sec.3800,Lab.CJ . ���
I YollCy NO. ComP3ny FOR AP�LICANT TO FILL IN J00 / p� �9
� New Residentiel BIdqS.&Pool6 EACN NO� FEE ADORE55 ZC� �I�'�t'7 �O'�� .
❑ Certified copy is hereby furnished. 1&2•Family,Sq.Pt. $ — $ LOCALITV �i/9��Uy"
• � Certified co g P Multi-family Sq.Ft. A
py is filed with[he county bulidin ins ection Residentisl Swimmin Pools CROSS S7 Oi+�
department. 9 OWNER OR LA
� FIRMNAME I`Y�'IO, /M�L ����5
Date Applicant Outlets:Rec._Light_Sw._ qpORESS ��� � 4'�
First 20
CERTIFICA7E OF EXGMPTION FROM WORKERS' Totai No. Additi0nal . CITv TN No.
COMPENSATION INSURANCE }
PLAN CHECK � � d
(This secGon need nol be completed if the work involved APPLICANT O
� by the permit is for o�e hundrcd dollars (SI00)or IessJ Lighting Fixtures First 20 ADDHESS
� � Totel No. Additional, �
�I certif that in the � � �
y performance ot ihe work tor which ihis Fixed Appliances Not Over 1 HP CiTv T�1 No. F
permit is isuued,I shall not employ any person In ony manner pEqM�T s U
w as to become subject to the W'orkers'Compensetion Laws. Ranqe_Heater D,W._ APP�ICANT `I�•/�Or+QiC,S� L`LFQ. a
/J_��,,c OVen _Drya�_W.M._ � ADORESS f' t�ifV��� Z
Date �2L��ppplicant��T+DG�/�/ � Top _FAU _W,H._ � —
Hood_Fen _Other_ � CITY �f�iv'"� Tel No.Sys—p/O'�
' NOTICE TO APPLICANT:If,efter making this CerNficale ot Disp. _Room Air Cond,_ LICEN E R
Exemption, you should become subject to the Workers' REG.NUMBER 2-G1- Cla�s C^/O
Compensation provixions of ihe Labor Code,you must forth- power Apperaws&Large Appliarxes DISTRICT NO. PR SED BY -
with comO�Y with such provisions or�tMs permit shall be Size&Type HP,KW,KVA,or KVA
deemed revoked. .Z / �j v'� ��nt`
Up ta 7 Incl. �P '
FINAL �
. Over 1 to 10 Incl, DATE
LICENSED CONTRACTORS DECLARATION pver 70 to 50 Inc�, VALIDATION
t hereby affirm that I am Iicensed under provisions of Chapter Ovar 50 to 100 Inc. FINAL
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 Bv �
ness and Yrofessions.Code,end my license is in full force end
effect. y� Services
Ucense NumberJ7��� Lic.Class G�O 0-200 Amp.Under 600 V � � 0 "`� (;3 q�}
201•1000 Amp.Under 600 V
Contracto�S� Date �'7'2�� Wer 1000 Amp,or Over 600 V #t � .� � ��
HOME OWNER-BUILDER DECLARA'IION Temp.Power Pole&Appurtenances � e •�Q,�(1
Si9n wich One Branch Circuit ('� . �o��^(1?
1 hereby affirm that I am exempt from the Contrector's P� yj �` °
License Law tor the tollowing reason (Section 7031.5,Busi- Additional Sign Branch Circuits � i �
ness and Professions Code): _ , '��� ��.2�—��
Miu.Conduits&Conducrors ,��
� t, es owner o(the property,will do the work and the p�har(See Completo Fee Schedulel—
structure is not intended or offered for sele (Section � �
T044,Busineas and Professions Code). ' �
CONSTRUCTION LENDING AOENCY .
1 hereby affirm ihut there is a consttuc[ion lending agrncy
for the performance of the work for whkh this permit is pERM1T FEE (Sub-Totell Q �
issued(Sec.3097,Civ.C.). eZ� - � �
LendoPs Name PLAN CHECKING FEE (One-Fourth Permit Fee) �
Lender's Address PERMIT ISSUING FEE . g �
I certify that 1 have read this application and stace that the TOTAL FEE ,j . .
above information is wrrect.I agree to comply with all Cminty
ordinances and Stale laws regulating Eleciricai wiring, and . .
hereby authodze representatives of this County to enter upon ' ' .
the above-mentioned property for inspection purpoaes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
�i�'�'t.o'l� r'L2-�7
Signature of ermittee Uate .
. \ .
� ` � �� OIC�'CR-GUILDGR D6CLA2ATI0\ '
_, .- . _ ,_ • ,
• ' ' � ' - '� ' �' � I hcreby affirm tl�at 1 am ezempt from tlie Contractnr's
._.._ _._ .... ..._ _. ' . . . . _..,.. _.
� �qFaftova�s DATE INSPECTOH'S � LiCcnsc La�c for thc fullowing rcason/Section 7031.5.
, , .... ' SIGNATURE -- � � LJIJSlItP55 arrd Projesriau�CodeJ: A�ry city or county
�� � � -�- - � . ��TEMP.POWER POLE � - - ' � K'hiCh �eqt[irer a perm!( to ronrm�ct, alter, irnprove,
� �- "" � - UN�ERSLAG l"JORY � demolish,or repcir any s7nrct+nc,prior to its issuante.
.. also requirea tLe app7icettt jor suclr pennir to fife a
- ' � � ��tOucti coNOUtT - --� -- - - � � siened statenrem rlrat he is�licertsed,pursumu to tlrc
, , - . . . . wi�tt�ic _ .1,-�- • prorisimts of�he Con7mcror's I.rtensc Law/Chapler 9
_ � _ (eornmeiicinS wkl� Section 7000/ oj Diririort 3 of the
� - . � . . � � FIX7uRES�- -� � - � � � ' I3usineas m��Professior.a Code/ ar that l�e it esempt
. „ , � tdesefrrim and'rhe basrs for!hc a!leged exemption.9rry�
� . -_ __- Fovder,nUriior,izeo I � rialationoJSertion7031.5Gyanyapplicantjorapennrt
� unu-rv co.rdonFi=.o � - sub/ects rJre applieant to a ciril penalry of rot morc tiran
� � � fi�r iumdred do7lars(5500/.: �� �
. . . . FINAL �� L'��t�cd wt �2aszL ,. ❑1,as on�ncr of thc property'xill do the e'orA,and
- ' � Nores � - . - , the structurc is not intended oc o(fercd for sale.
, -- . - - . — _. . /Sec. 70-0-0, I3usiucss aad Professinr,s Cude.• The Con-
. , . , .. � � . � - .fraeror's /.icrnse f.aw�does no7 appf}� !n an oicner oJ
` , property who builds or impro��es the�eax,ar.J srGo does
� - . . , such �corh.liirnseff prorided Uiat suc1+ improremettts
. - „ , , �, . ore not Lrtenrled o/offered jor sale. !j, l�owever, d�e
' , � . � —� • . . � �. . ' � ' .builAing or irrtprovenicrrt u sold widiiu orie ycar oj
, , , complelioir, tke ou•irer-6:iilder wil! hare the burde��
� ". - "`. . "'.....- -'-" ' . ' ' � . , of.proring,lkan c� did not.burld or improre fnr.the
. , ��rpose of sale./�- . �
_. [am exempt under Sec. ,
. � . _ � B�P.C.for this reason
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