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WORKERS'COMPENSATION DECLARATION �� �0•81 � qpPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm ihat I hove a[e��ificate of consent to sel4 CE�806C
insure,or a cartificote of Workers'Compenwrion Insurance, . COUNTY OF LOS ANGELES BUILDING AND SAFE?Y
or a c,rtlt_iet1�p�0��(�`Sec.3800,Lab.C.)
P❑ol�icy tJo l} � Gbmpo^Y�}'.��YL.-p�� FOR APYUCAM TO itLL IN . A�E�t� 014�
Certified copy is hereby furnishad. New Residenlial Bldgs. P olz EACH NO. FEE
� Cart�f�ed copy is filad with�he counry bocldtng inspac- �8 2-Family,Sq.F�. ���� s — S I�CAUTY
tion departmenL Multi•fomily Sq.FI. — ��ST � }
p [� Residential Swimmin Pools CROSS ST. 7
Do1e�'G+�(�� Appliconl Y�p-L A���PC1L�r 9 OWNER OR
FIRM NAME� G
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Ree�LigM�Sw� Ma'« �.� �
M.
- COMPENSATION INSURANCE ADDRESS � 1 ' .)
Thfs aecllon ne�d not 6�com I�t�d if th�work involv�d b / Firsl 20
( P r lotal No. ..'1 CITY Tal.No. �
1h�p�rmM is for ono hundr�d dollon(5100)ar I�as.) Additionol [�7
I cerlif that in ihe (ormonce of the work for which this 7lAN CHECK V
Y Pa� APPLICAM
permil is issued,I sholt not employ any person in any manner
so os 10 become s�6ject lo the Workars'Compenwtion Laws. Lighling Fiztures First 20 ADORESS
Tofat No. Addi�io�al
� CITY Tel.No.
pore Applicant FiKed Appliances No�Ovar 1 HP pERMrt
N0710E TO APPUCANT; If, a(ter moking Ihis Cmtifico�e of APVLiCArIT �
Exemption, you should become subjacl to the Workars' Ronge_Heole�_D.W._
Compensdlion provisions o(the Lobor Code,yodmusl forth- Oven _Dryer _W.M._ AODRE55 5'
wi�h comply w'th s�ch provisions o� this permit shall be 7op _FAU —W.H.—
deemed revoked. � Hood _fan _O�her_ CITY Tal.No:
, UCENSEO CONTRACTORS DECLARATION �ICENSE OR
� I hereby offirm ihot I pm licensed under provisions of Chapler 9 Disp. _Room Air Cond. - REG.MUMBER C(� � Closs.
(commencing wilh Section 7000)of Division 3 oF the Business powe�P.pparotus 8 Large Applibntes DISTRICT NO. n PROCESSE BY �,
� ond Professions Code,and my license is in full force ond effect. ! � d
f Size 8 Type HP,KW,KVA,or KVAR / �
license Number��3 z7O Lic Closs� Up to 1 Ind. FINAL ,/ � V
� p C Over 1 to 101nd. OATE Lf�f� pY VALIDATION �
Contracto�nn�AA�n nl�<<" Date-���–n� Over 70 l0 50 Intl. d V
❑ FINAI
I om ezempl under Set. Over 50 fo 700 Inc. B , 2G�1/ �
B.&P.C.for ihis reoson Ovar 100 Z
Date: Services,Sw6d.,MCC 8 Panelboa�ds ,
0-200 Amp.Under 6W V
Signature 201•1000 Amp.Under 600 V
OOver 1000 Amp.or Over 600 V
Exemprion for Reg.Maini.Elect.
SINGLE FAMILY Tamp.Power Pole 8 Appurlanonces r� 4�,3 A
HOME OWNER-BUILDER DECLARATION Sign wi�h One Branch Circoit �� � � � �2
I here6y afflrm thot I am e:empt from the Controc�ar's License _ Additional Sign Branch Circoits '
law for ihe following reason{Se<tion 7031.5, Business and -
Professions Code): I • �9 2 4 4
❑ I,as owner of ihe property,will do ihe work o�d the Mix.Conduits 8 Conductors • • .q 2 4 4�
siructore is no� intended or offered for sale (Sec�ion Other(Sae Complate Fee Schedule)_ , -
7044,Business and Professions Code). � �2 Q']=8(�
CONSTRUCTION LENDING AGENGY � � - �
I hereby affirm Ihat ihere is a conslruUion landing agancy for
Ihe performance of the work for which ihis permit is issued pERMIT FEE ($vb-Totol) .
(Sec.3097,Civ.G�.
PLAN CHKKINPi FEE �
lender's Name
Lender's Address
�1()Q rS.l�C�� eQ– �RMIT ISSUING FEE p
I certify�hat I hove reod this applico�ion and state that Ihe TOTAL FEE
above information is corract.I agree to comply with all County �
ordinoncas and Stata laws regulating Elettrical wiring,ond
hereby outhorize represeNativas of this County to enler upon - .
rhe above-memioaed prop ry for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
C e' " �—��'�
ignarure of Per in e Da�e - '
�
' � �APPROVALS � DATE _ . � OWNE�-6UILDER DECLARATION
�� . � . SIGNATURE �
TEMP.POWER POLE � -� , , � ' I hereby affirm thot 1 em exempt trom,ih�Controctor's
� �- -- � ' � � License law for the follawing reason (Secl/on 7071,5,
, UNDERSCABWORK . , , BuefnessandPro/ossloosCode):AnyclfyorcouMywfi:ch
• ROLIGH CONDUIT '� �1 - requlres a permf�lo aonstruct,alfer.ImProve,demoflsh,
.. . . _ . .. or rcpalr ony strucfurc,prlor lo Hs issuonce, olso ro-
� WIRING a , . , qufros the applieant forsueh permlt fo filo a slgned srofe-
-- .- �� ' - monf fhat ha!s llconsed pvrsuant ro the provisions of Ihe
FIMURES � -�-- � . � Contracfor's License Cow(Chaptcr 9(commendng wnh
- - POWER AUTHORIZED � - � �� Secflon 7000J of Dlvision 3 al Ihe 6uslness and Fro(es-
. sfons Code)or fhaf he Js exemp!fherefrom and�he bas;s
- _ � � � UTILITY CO.NOTIFIED � for !he alleged exempflon. Any violatlon of Sectlon
- - --� FINAL � c� � ' . 7031.5 by any applimnt(or a permlf svbJects the eppfi-
Gafer on �Y'nnf cant fo a civll portaNy o/nof mare Ihan Ove hundrod
�-� � -�NOTES ---- � - ' , , dollars(5500).:
� � ❑I,as owner of thc property will do tho work,ond
� - - Iha sfrutturo Is not tnlended or offered for sole.
� (Sec.704f,Bvffness ondProless7ons Code:,ibo Confroc-
for's Licensc lavi doos no�opply}o on ownor o(property
. - _ . . . . . - � � w6o 6ullds or Improvcs Ibereon, and who doet such
work hlmsoH provlded fhof suth(mprovemonts are no!
-� � � � - � , � Intendod or ofFcred for sale.ll,however,fhe bWfding or
� � improvemortt Is sold wi}bin ono year ol complefion,�he
. � owncr•bulldor wlll have}he 6urden ol proving}hot ho did
� - � not build or Improve lor�ha purpoee of safa)
'. � ' . . __ . .. _ � ,
� I am exempt under Sec. ,
. B&P.C.for lhis reoson
Dare
. - , , Owner �