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WORKERS'COMPENSATIONDECLARATION �� �0�81 qpp��CATION FOR ELECTRICAL PERMIT �
I hereby offirm that I have o cerlificate of consent fo self �E"�
insure,or a tertifica�e of Workers'Compensation Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAfETY
or a cer�ified copy therao (S 3800,Lob.C.)
''�I'� c
QCy No.l�� m ny�� FOR A/PLILANT TO Hlt IN JOB
Ce�lified copy is hereby furnishad. New Residentia)Bldgs.& ools E'°'�H NO. FEE ADORE55 �/
� Ca�tifiad copy is filad with the counly building inspec- �g�-Family,Sq.FI. E — S �«A��TY
� lio de ort nt. - Mulli-family Sq.FI. — NEaRE57
{ y� N� Residentiol5wimmin Paols CRO555T. �J
Da1e-��—APPlimnl(„���•IC�!L!C�l.ti-I�p 9 � OWNEaOR
FIRM NAME'
CERTIFICATE OF EXEMPTION FROM WORKERS' ��j � ?i r� M IL
COMPENSATION INSURANCf Outlats:Rec Light firs510 �7 AWRESS °1'
(Thls sdien nNd nof b�compl�t�d ii tM work involv�d by Total No.� C�TY Tel.No
th�p�rmN b ter en�bundr�d dellon(f100)or Ins.) Addiiiona�
I certify thot in the performanca of the work fw which this APPLICANTK
permit is issued,I sholl no1 employ any person in any manner
so os lo become subject lo the Wakers'Compennotion lows. LigMing Fialuras � First�0 � ADORE55 '
Total No. Addifional
Oa�e � applicaM ' CITY Tel.No.
NOTICE TO APPLICANT: If, after moking this Cerfificore of Fixed App�ionces Nor Ovar 1 HP PERhvT
Exemption, you shouid become subjacf to 1he Workeri Range_Heater_D,W._ APPIICANT
Compensation provisions of the Lobor Code,yoo must fo�1h- Oven _Dryar —W.M._ � ADDRESS
wilh comply with suth p�ovisions or Ihis permit shall be Top _FAU _W.H.—
deemed revoked. Hood _Fan _O�her_ GITY Tel.No. -
UCENSED CONTRACTOkS DECIARATION uCENSE OR
I hereby affirm tho�I am licenxd under provisions of Chapter 9 'Disp. _Room Air Cond. _ REG.NUMBER' Clpss.
(commencing with Section 7000)of Division 3 of the Business power Apporufus 8 Lprge Applipnces DISTRICT NO. PROCESSEO Y �
a�d Professions Code,and my lice�x is in full forte and effecf. d
���f�\/ Size&Type HP,KW,KVA,or KVAR ��� �
license Number.�(�LL�_!�L_�Lic.Class� Up l0 1 Ind. ' V
FINAL
� ContraU ' Date�_ Over 1 to 101nc1. OATE � lJ �� VAUOATION �
❑ � Over 10 l0 50 Incl, FINAL 7 O
I om exempt under Sec. Over 50 to 100 Inc. BY uvi
B.BP.C.ior ihis reason Over 100 y
. Services,Swbd.,MCC 8 Panelboards ► � - ?
. Daie: 0-ZW Amp.Under 600 V
��, Si9no�ure 201•1000 Amp.Under 600 V ' �
❑ Over 1000 Amp.or Over 600 V ��.
Exemplion for Reg.MoinL Elec1.
SINGLE FAMILY Tamp.Pawar Pole 8 Appurtenances
HOME OWNER-BUIIDER DECLARATION Sign with One Branch Circuil `�� 4�.6 A
I bereby affirm ihat I om exempt from ihe Coniroctor's Litense Additional Sign Bronch Circuih �• • � e •'2
Low for the following reoson(Seciion 7031.5, Business and �
� Professions CodeJ: . ' • •9 S 4�
aI,as owner of the property,wiil do the work aod the Misa Conduits 8 Conductors -
stroclure is nof intended or offerad for sule �Section O�her(See Complete Fae$chedule)_ , . • •G rJ 4 4.•.
v
7044,Business and Professions Code). � '
CONSTRUCiION LENDING AGENCY � . O P.D 7`S A
I he�eby affirm thal Ihera is a constrvction landing agency for � �
rhe pariormance oi the work for which this permir is iuued PERMIT FEE (Sub•To�al) . .
(Sec.309�.Civ.C.). . �
/���/� Y'V\t� , /� !J PLAN CHECKING FfE
Lender's Nome`"� �
�,���c�1` `• PERMIT ISSUING FEE � D
Lender's Addres c � � -
I certify thar I hove read fhis applimtion and siore thoi rha TOTAL FEE C
above informa�ion iz correct.I aqree 10 comply with all CouNy � � �
ordinonces ond$tate lows reguloting Electricol wiring,ond �
hereby authorize representatives of Ihis County�o enbr upon �
the a6ave•mea�ioned propert for inspec�ion purp�es. SEE REVERSE FOR EXPLANATORY IANGUAGE ', � .
gnature of Permi e `Date
. . APPROVALS � DATE � . ,.OWNER-BUILDER DECLARATION�
. • SfGNA7URE
� TEMP.G01NER POLE . - � � � I horeby oifirm 1ha�I am exempi from�hc Controctor's
- �� � - � -� Licenee Law for tho following rcason (SccNon 7031.5,
. UN�ERSIABNlORK. _ , OuslnessondProfoss7onsCode):Anyclfyorrountywhlcb
� fi3OUGH CONDUIT � g'3 � � ' requfres a pormlt lo canslrucf,alter,lm�rova,demohsh,
. . or repvlr any sfrudore,prtor fo Ils rssuonce, olso re-
WIRING (a , qulrssfheoppficant(ors�chpermlffoflloastgnodsfale-
- FIX7URE5 - ' � .- , . men!ihatha Isl7censadp�rsuanl fo fheprovlslons o/tfio
� � - , Conlratlor'a Lfcrosa Low(ChopMr 9(commenUng wlth
FOWEA AUTHORIZ[D - " � Secflon 7000J o!Dlvlsion 3 0(fFe Buslness and Proles-
slons Code)or fhaf ho!s exempt fhwelrom and thc basls
UTILIN CO.NOTIFIED � /or Ihe�olfe9ed exempllon. Any vlolaHon of Sectlon
, � -- - FINAL �nfc�ors yron( 703L5 6y ony appl(canf for a permlt subjetfs fhe opp11-
, � , . cant fo a eivll penalfy of nof more lhan flva hundred
- -- NOTES dolfaro(5500).:
� . ❑I,as owner of iho property will do Ihe wwk,and
- � fho sMucture is not Intonded or offcred for sale. .
. ___ _ _ ' - � (Sec.7044,Sualnvss and Prolossions Code: iho fantroc-
!or's Licensr Low docs no�apply to an owner of property
� - . _ ._ � _ � who bu(fds or Improves ihereon, and w5o doos suc6
� wark hlmself provldsd 160�such Improvemonts are nof
� . . ' � � - . . Intendedorol/cred/ormlc.11,6owwer,fhebulldingor
lmprovemenf!s sold wl�hln one yeor o!completlon.1hv
. , � ' ' owner•bWlderwtllhovetheburdenofprovingfhathedid
� not 6uildor Improve lor ihe purposc of safo.J
�� � ' I am exempt onder Sec. � ,
�
. B&P.C.foc fhis reason
Date
Owner