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WORKERS'COMPENSATION DECIARATION 76A663 ,o�a, APPLICATION FOR ELEGTRICAL PERMIT �
I hereby offirm that I have a cerliiicate of consenl to seli CE-806C'
insure,or o cerKfitata of Workeis'CompensoYon Insurance, COUNTY OF LOS ANGELES BUILDING AND SAF�Y
or a ce�iifi c y thereo c 3800 .C.)
P❑o�icy No. ompony � FOR A/PUCAM TO i1141N JOB % � �7 C
Certified co is herob fumished. FACH NO. FEE ADDRE55
� PY Y New Residen�iol Bldgs.&Poola ,n��
LOCAUTY
Cerlitied copy is filed with the couNy building inapet• 1&2-Fomily,Sq.FL�/� _ f — S N,�r�
iio de rr nt. �,..�. Multi-family Sq.FL — t�naEST /� �
��,��(�«�� Residen�iol Swimming Pools ���St. ��
Date 'L�f a��' Applicanl�l OWNER OR
. FIRM NAME
CERTIFICATE OF ExEMPTION FROM WORKERS' Ou�lets:Rec�Light�Sw.� �`��
COMPENSATION INSURANCE F.5�p ADORESS �
(Thb��Nion ne�d noT 6e eempl�bd�i Ih�work invelwd by Total No. � qddilional CITY Tel.N ��)
fb�parmiT b►or on�hundr�d dollon(SI00)or I�ss.) PtAN C fCK
I tartify that in the performance of ihe work tor which this rauGqNT
parmil is issued,I sholl not amploy any person in any manner
so os to betome subjeU to Ihe Workers'Compenwfion lows. Lighting Fiafu�es Firsl 20 �� ADDRE55
Total No.� Additional
Date ApplimM CITY Tel.No.
NOTICE TO APPLICANT: If, after making this Ca�tifitate of Fixad Appliances Nor Over 1 HP PERMIT
Exemption, you shouid become zubject lo the Wo.kers' Rongg_Henfer_D.W._ APPLICANT
Compensaiion provisions of ihe lobor Code,you must forrh- Oven _Dryer _W.M._ ADDRESS � � �
with comply wilh suth provisions or this pe�mit sholl be Top _FAU _W.H.—
deemed revoked. Hood _Fan _Orher, CITY Tel.hlo.
� IICEN$ED CONTRACTOR$DECLARATION IiCENSE OR /
I he�eby affirm Ihat I am licensed under provisi0n5 oF Chopfer 9 Disp. _Room Air Cond. _ REG.Nl1MBER 4' CIa55.
(commencing with$ection 7000)of Division 3 of the Businnss DISTRIC7 NO. PROCESSE�
and Profeuions Code,and my license is in full force and affect Power Appordtvs 8 Lorge Appliances }6
n Size 8 Type HP,KW,KVA,o�KVAR l� �
. License Number Lit.Closs� FINAI � V
.Up to 1 Incl.
Conirattor'--"'""'� Date� Over I to 10 Incl. DATE � q �.�/ VAUDATION �
/ y' F
❑ Over IO to 50 IncL FlNAL _
I am exemp�under Sec. Over 50 to 100 Inc. BY �
B.&P.C.for this reason Over 100 Z
Date: Sarvices,Swbd.,MCC 8 Ponelboards ► - , ,
0•200 Amp.Under 600 V
Siqnorure Z01-1000 Amp,Under hW V
� Ovar 1000 Amp.or Over 600 V '
Exemp�ion for Reg.Moin1.Elect.
SINGIE FAMILY Tamp.Power Pole 8 Appurle�onces
HOME OWNER-BUILDER DECLARATION � Sign with One Branch Circuit
1 hereby affirm ihot l om exempt(rom fhe CoMractor's license Additionol Sign Braoch Circuits ?=� (G�,(1 F
Law for the following reasan(Sec��on 7031.5, Business and
Professions Code): �• • • • �'Z
❑ I,as owner of the property,will do the work and the Misc.Conduits 8 Conduc�ors
srrudure is not in�ended or offered for wle(Section Other(See Complete Fee Schedule)_ � • •9 5.4 4
7044,Business ond Professions Code). ► . �9�4 4`
CONSTRUCTION LENDING AGENCY - • •
I hereby affirm thot fhere is a conslrucfion lending ogency for , �G�7—8 1l
the performonte of Ihe work for whith Ihis pe�mi�is iss�ed pERMiT FEE (Sub-Toial) � -
(Sec.3097,Civ.C.). � � �
� r i i PLAN CHECKING FEE . .
Lender's Nome G � .
) PERMIT ISSUING FEE
Lender's Address �
I ceriiiy that I have read this appl�mtion and srare that the TOTA�FEE �.�'r� � �
above information is correct.I ograe lo comply with oll County
ordinonces and State laws regulating Electricol wiring,and
hereby authorize represeMatives of this CouNy to ente�upon �
the obove-menntione p operty for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
'.C` z—�p�'
norure of Per �ue Dote � �
� �-� � �APAROVALS - DATE - � _ _ __ , � • OWNER-BUILDER DECLARATION
� . � . - � SIGNATURE �
� " TEMP.POWER POLE - � � I heraby affirm thot I am exempr from thc Conrroctor's
� � � �� ' � licenso Low for tha following reason (Settfon 7031.5,
' UNDERSLABVlORK . . ' � BuslnessandProfesslonsCode):AnycityorcouMywhlch
'� � ry � � roqWres a permit fo eonslrvcf,alfe�,'improve,demollsh.
- ROUGH CONDUIT Q or repair any struc}ure, prfor to Ils Issuanca, also re-
� - WIRING � . yvlresfheoppfleonfforeuthpermltfofileos(gnedsfafo-
. - � - � men�that he fs flcensedpursuaN fo fhe provisions of Ihe
� . - - FIXiURES - � . � � Conf�acfot's Llcanse Low(Chaplcr 9(commencing wllh
� � � � � - � POWER AUTHORIZED � ' - Secflon 7000)ol DiNslon 3 of Ihe 6us(ness ond Proles-
. - ��slons CodeJ or Ihal he Is exempl fherelrom and the bosis
' - - UTILITY CO.NOTIFIED for fhe alfeged exemptlon. Any vlolatlon ol Soctfon
- - FINAL - r 7031.5 by any appllcont/or a pormft su6Jads ihe appli-
Gnler on ��ort� cont fo c clvtl penafly of not more than (Ive hundrod
, NOTES- - , � � doIlan(S500J.:
, - . � � �� ❑I,as owner of fho property will do tho wo�k,and
- 1ho structure is nof inlendod or offored for sale.
�� " � (Sot.704�,Dus7nessandProfesslonsCode:�.TheControc-
� � �for's Ucense Law does nof appfy to an owner of properfy
__ .. . _ who bul(ds or lmproves fhereon, ond who docs such
� ' work hfineeB provided}hal tuch Improvemenfs o�c not
� � � - � - ' � � Infended or offcred far sofe.If,however,1he 6vlfding or
� 'Improvemenl is sold wlfhln one yeor o!completion,fhe
� , �, � - ' � owncr-buffderwlllhavethe6vrdonofprovinglho}hcdid
. � � . � � nol b�ffd or improve for!he purpose of salo.)
" ' - � I am exempt under Sec. ' ,
� . .B&P.C.for this reason
Dote
Owner
.