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WORKERS'COMPENSATIONDECLARATION ��� ��.81 APPLICATION FOR ELECTRICAL PERMIT �
I herehy aFfirm that I have a cenificate of consen��to snlf CE-BO6G .
insure,or a certifico�e of Workers'Compensa�ion Insuronce, � COUNTY OF LOS ANGE�ES BUILDING AND SAFETY
or a certified copy�hereof(Sec.3800,Lab.C.) -
OcyNo. Company FORAP►LICANTTOFI►lIN A�E� �1Z,5— �,1`,�,(J�� W
Certified copy is here6y furnished. New Residential Bldgs.8 Pools EAGM NO. FEE � � C"t��'��
❑ LOCALIN _
Certified copy is filed with the county building incpec- 1 8 2-Fomily,Sq.Ft. S — S �
tion deporlmenL . Mulli•fpmily$q.Ft. — NEAREST T �
� � Resi nlial Swimming Pools CitO555T. J/ ��
Dote � A IiConl - OWNFR OR ('"�
PP � aC FIRM NAME �Y"'� `�t:��
� CERTIfICATE OF EXEMPTION FROM WORKERS' Outleta•".Rec_Light_Sw._ �'Jj°'��
COMPENSATION INSURANCE - nDWtESS �{�i .
hi�sMion nwd net b�eem IN�d if th�work In�olwd b Firs�20
� p Y Total Na � CITY Tel.No
. th�p�rmM is}or on�hundnd dollen(f100)or I�ss.) � � Addi�ional �� '
I te�tify Ihot in Ihe performonce of Ihe work for which lhis - � , AVPINCANTN � �
permil is issued,I shall noi employ ony pe�son in ony mpnner �
so os to become subject to the Workers'Compensation laws. Li9hting Fixturas First 20 ADDRESS �
Addi�ionol
Tatal No. CITY � Tel.No.
Dale�pplitan —' ' Fixad Appliantes Nof Ove�1 HP P[RMIT
NOTICE TO APPLICANT: If, af aking ihis e tificate of APPLICAM
Exemplion, you should betome subjecl to 1he Workers' Range_Hea�er_D.W.—
Compensation provisions of fhe Lobor Code,you must for�h- Oven _0.yer _W.M._ ADORESS
with comply with such p�ovisions or ihis parmit shall 6e Top _FAU —W.H.—
- deemed revoked. . CITY � - � Tal.Na �
Hood _Fo� _Ofher_
IICENSED CONTRACTORS DECLARATION UCENSE OR
I hereby affirm fhal I am licansed under provisions of Chapbr 9 Disp. _Room Air Cond. — REG.nlUheBER C�au•
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PROCESSED Y
and Professions Code,ond my license is in full force and effact. Power Appuratus 8 Lo�ge Applionces . _ �
. _ Size 8 Type HP,KW,KVA,or KVAR l� -�'«� Q
License Number Lia Class - Up�0 1 Incl, FINAL �/ - V�
. - Over 1 la 10 Incl. DATE h%/�/�� yALIDATION �
Cantroctor Date Over 10 to 50 Ind. FINAI✓',� O
. ❑ I am exemp�under Sec. � Over 50 to 1001nc. gy �i''""� '��� V
� W
- B.BP.C.for Ihis reason �� ��'��/~��
Over 100 Z
Date: Services,Swbd.,MCC&Pa�elboards , _ �� � �'
0-�0C1 Amp.Unds�600 V
Signature 201-1000 Amp.Under 600 V - �
❑ Ovar 1000 Amp.or Over 600 V � �
Exemp�ion for Reg.MaiN.EIeU.
SINGLE FAMILY� Temp.Power Pole 8 App�rienances
HOME OWNER-BUILDEl1 DECLARATION Sign wifh One Branch Circuif �0 9 3.S A
' I hereby affirm tha�I am ezempt from Ihe CoNractor's License qddilional Sign Branch Circuits �
Law for Ihe following reason(Section 7031.5, Business ond � � #� � � � �2
, Professions Code): ' � � -
� ❑ I,as owner of the property,will do the work and the M:x.Conduits 8 Conductors � • •3 Q Jc O .
strocWre is no� intended or offered for wle(SeUion Othar(See Complele Fee Sthedule)_ ► ' -
� 7044,Business and Professions Code). •3 Q 5 0� �
CONSTRUCTION LENDING AGENCY . O�.� O—8 Q
I hereby affirm that ihere is a construUion lending agency for � • �
the performonce of the work for which this permi�is issued pERMIT FEE (Sub-To�ol) �� � - �
� (Sec.3097,Civ.C.�. � � � � � �
� PLAN CHKKING FEE � - � � .
Lender's Name �
. PERMIT ISSUING FEE I� � .
Lender's Address �
I certify Ihaf I have read Ihis applimtion and state thot Ihe TOTAL FEE �Q.SO ��
above information is correct.I agree to comply with all Couniy .
ord�nances and State laws reguiating Eiectrical wiring,and . � � �
hereby authorize representa�ives of this County to enfe�upon . . .
� e obove- �ion d roperiy for inspect�on purposes. . . �
-� �- 1-`1-��}-
� SEE REVERSE FOR EXPLANATORV LANGUAGE . . .
re of Permi e Date `
i
�APPROVAlS DATE . _ OWNER-BUILDER DECLARATION
� . SIGNATURE
TEMP.FOWER POIE I herchy affirm that I am cxempt from thc Cantractor's
: ' -- Li[emo Law for the following rec.son (Seclfon 7031.5,
' UNDERSLABWORK � Buslne55andProfesslonsCode):Anycifyorcountywhlch
. ROUGH CONDUIT � reqalres v permlt ta tonsfruct alfcr,Improvc,demolish,
or rvpair ony struclurc,prlor to i�s Is�uance, also re-
' WIRING � V � qu(ros fho oppNmnt lor such permit fo flfe a slgnedsrote-
�" FIMURES . . .. � monl fhat ho ls 7leonsodpare�ant fo!ho provisions of the
. : Controctori Llcense Cow(Chapter 9(commenUng wl�h
POWfR AUTHORIZE� - - - Socflon 7000)of D/vlslon 3 0l fhe Dasiness ond Profes-
' sions Code)or thal ho is exempf ihcrofrom and tbe bas7s
- UTILITY CO.NOTIFIED � /or Ihe alleged oxempf�on. Any Nofa�lon o( Secllon
� FINAL 7031.5 by any applicant for a permlf sobjecfs Ifie appli-
. --�n(er on �ronl , cant fo.a eivll penolly of nof more lhan Ove hundred
� �- NOTES - � � dollari(5500).: � �
� , � � � . ❑I,as owner of tha property wiil do Iho work,and
iho stroaure Is not intonded or offered for sale.
' ' ---� - � � (Sac.7045,Bvriness and Pro/esslons Code: Tha Contrar
� " - " �� � lor s Utonse Law does not appJy fo an owner of properfy .
� _ . , who bullds or Improves fhereon, aod who does such
� work himscl/prov!dod ihai suth ImprovcmeMs arc no�
- - . _ . . _. ' Intendod or olFered for solo.N,however,the bulfding or
� Improvemont-1s sofd wRFin ono year o/comple}lon,Ihe
� . ; . owner•6uflderw111 have fho burden o!proving ihot he d�d
' ' nof build or Improvc for ihc purposo af sale.)
�
� ' I am exempt�nder Sec. .
B&P.C.for ihis reason
- Date
Owner
: �