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WORKERS'COMPENSA71�0 DECLARATION 76Afi63 APPLICATION FOR ELECTRICAL PERMIT ,I
- CE-B06G(2-80� '
1 hereby afeirm that I have a certi£[cate of cnnsent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY jj
insure,or a certificate of bVorkers'Compenaation insurance,or . �
a ceeti�ed copy thereuf t�c.3i�00,Lab.C.) •
�j Po�cyNo.'�a S3Company "��-�M��*�� FOR APPLICANT TO EACH'ty MO. FEE DORESS Z G/k" �i�[�h'�NF�' �
i New Residential Bldgs.&Pools
� Certified copy is here6y furnished. 1&2-Femily,Sq.Pt, $ — � LOCALITY ��,.� —��r'
Multi-family Sq.Ft. — EAREST
�CerHfied copy is filed with the county 6uilding inspection CFOSS ST
departmen[. Residential Swimming Pools OWNER OR
FIflMNAME Y�'..it��' "f'lF .C�('-L��
Date Appticant Outlets:Rec._Light_Sw._ AODRESS
First 20
- CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional
�COMPGNSATION INSURANCE CITY Tel No. T
P�AN CHECK � - d
(This section need.not he comple4od if Hte waxk involVed APPLICANT � Q
by the peimit is for one h�ndred dollars ($100)oi lees.) Lighting Fixtures �First 20 ADORE35 V
Total No. Additional �
I cer[ify that in the performance of[he work for which this - � CITY Tel No. �
erinit is issued,I shall not em lo an erson in an manner Fixed Appliances Not Over 1 HP
F P Y Y D Y PERMIT L�„t�y. /��L,� (�
� so as to become subject to the Workers'Compensation laws. Range_Heater_�.W,_ ApPLICANT C�+•H! ya.1
. Oven ,Oryer_W.M._ ADORESS �GLf ,!`�C�f�{S�la£ 117
� Date Applicant Top —FAU _W.H.._ � Z
. Hood_Fan _Other_ Ci7V _���6 7eiNo. 6�7�S^p S
NOTICE TO AYPL[CANT:If,aCter making this Certificate of Disp. _Room Air Cond,_ LICENSE R s—�OO
Exemption, you should become subject to the-Workers' REG.NUMBER � �'Ciass 4` ^�
Compensa[ion provisions of the Labor Code,you must forth- power Apparatus&Large Appliances DISTii1C7 NO. PFiO�SED eV
wi[h comply wi[h such pravisions or [Ais permit shall be
deemed revoked. Size&Type HP,KW,KVA,or KVAR �Q ����.t/
Up to t Incl. FINAL
OYef 1 to 101nC1. oATE ? J ��
� . LICENSED CONTRACTORS DECLARATION Over tOto 501nc1. � J VAUDATiON
1 hereby aFfirm that I am licensed under provisions of Chapter Over 50 to 100 Ina FINAL
BV
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 .
ness and Professions Code,and my license is in fu11 force and .
effect. Se�vices
License Number Lic.Class 0-200 Amp.Under 600 V
201-1000 Amp.Under 600 V
� Contrac[or Date Over 7000 Amp.or Over 6�V
HOME OWNER-BUILDER DECLARATION Temp.Power Fole&Appurtenances
I hereby affirm that I am ezempt from the Contractor's Sign with One Branch Circuit L 7 %'],Q A
License Law foc the fotlowing reason (Section 7031.5, Busi- Add'Itional Sign 8ranch Circuit5
#• • • • •2
ness and Professions Code): � �
� Misc.Conduits&Conductors
� I, as owner of the property,will do the work and the O r(See plete Fee Schedule)— �-• •2 Q 5 n
structure is not intended or offered for sale (Section � � �f � _
7D44,Business and Pmfessions Code). � '• •2�,J��o
CONSTRUCT[ON LERDING AC7ENCY •
I hzreby nffirm that there is a construction lending agency 0 3.0 8-8,e
for the performance of the wv�k for which this permit is pERMIT FEE (Sub-Tota1) (1
ssued(Sec.3099,Civ.C J. -
Lender's Name PLAN CHECKING FEE IOne-Fourth Permit Feel ,
Lender's qddress PERMIT ISSUING FEE � � �
I certify thab I have read this application and state that the TOTAL FEE n ��]
above informa[ion is corcect.I agree to comply with atl County . �
ordina ces and State laws regulatfng Elec[rical wiring, and - �
her y uthorize representatives of this County�to enter upon � �
th ab ve-mentianed p perty for inspection purposes. '
SEE�REVERSE FOR EXPLANATpRY LANGUAGE- �
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