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WORKERS'COMPENSATION DECLARATION 76A663 IO/BI ppp��CAT10N FOR ELECTRICAL PERMIT �
I hare6y affirm ihat I have o cerfifica�e of consent to saif �'�
insure,or a cenifitate of Wo�kers'Compenwiion Inwrance, COUNTY OF LOS ANGELES BVILDIN�s AND$AFFTY
or aser„(ifja,d4o.py�he�i c.3800,tobo.C.)
❑-Ycf�c13 ClT•��aa�Y Mc� d�
Polic No. C m FOR AP►UCAN7 TO Rll IN JOB �
Certified copy is heraby furnished. New Residential Bidgs.8 Pools EACN NO. F E ADDRESS�
� Cartified copy is filed wirh ihe county 6uilding inspec- 1&2-Family,Sq.Ft.J�y f' — f ���+�IiY
�ion de r7ment. Multi•fomily Sq.ft. —
NEAREST
/j�.(Q�Q(!, U���p�j�/ ' Residential Swimming Pools Cko5557.
Data='�=�.AL(___APPI imn� F�IRM NAME
CERfiIFICATE Of EXEMPTION FROM WORKERS' Outlets:Rec�Li9h1 � Sw.� � ��� ,cs�
COMPENSATION INSURANCE wooitESS s+V
7his s�ction n��d eM 6�cam I.r•d N rh•work tnrelv.d b First 20
( P Y Tobl No.� " CITY Tel.No
1h�p�rmif is►or on�hundred dollurs(5100)or I�s�.) Additlonal a
PIAN CHKK
1 tarfify thot in the performanca af the work for which ihis ' APPLICANT
permit is issuad,I shpll not employ ony person in ony monner
so os to become su6jeU io the Workers'Compensalion Laws. Lighting FixWres First 20 ADDRE55
To1al No.� Additional
QTY Tel.No.
Oa�e opplicam Fixed Applionces Not Over i HP pEpMiT
NOTICE TO APPLICANT: If, after making this Certifico�e of AGPIICAM
Exemption, you should become subjacf to the Workers' Ronge_Healer_D.W._
Compenwtion provisions of the Lobor Code,you mus+forth- Oven —Dryer _W.M.— ADORE55 � , �
with comply wi�h such prov�sions o� this permit sholl 6e Top _FqU _-.W.H.—
deemed revoked. Hood _Fon _Other_ CITY ' Tal.No.
LICENSED CONTRACTORS DECLARATION uCENSE OR
I hereby affirm that I am licensed under provisions of Chaptar 9 Disp. _Room Air Cond. — REG.NUMBER l�i3z7�S Clax. �
(commencing with Section 7000)of Division 3 of the Bos�ness DISTRICT NO. PROCEJ Sd'�'�"'
and Pwfessions Code,o�d my license is in full force a�d eifeU. �owef ApporoWs 8 La�ge Appliances , , aY
�j 51ze 8 Type HP,KW,KVA,or KVAR �0 p
License Nomber ( ,�'v7� lic.C�ass� Up l0 1 Incl. � � ' FINAL V
���{�������q+. �� Over I fo IO fncl. DATE 3/Q �7l� VALIDATION 0
CoNroctor�.[ll{r �]ale � �
❑ Over 1D to 50 Ind.. FINAL . ~
I am exemp�under Sec. Over 50 to 100 Inc. BY 4
B.SP.C.for Ihis reason Over 100 Z
Date: Services,Swbd.,MCC 8 Panelboards ,
, 0-200 Amp.Unde�600 V �
Signolure 201-10p0 Amp.Under 600 V
OOvar 1000 Amp.or Over bOp V � �
Exemption for Reg.Main�.E�ect.
SINGIE FAMILY 7emp.Power Pole&Appurtenonces �
HOME OWNER-BUILDER DECIARATION Sign with One Bronch Circuit � S 1 5&5 Fl
I hereby offirm thot I am exempt from the Contracror's License Additional Sign Branch Circuits
law for Ihe following reason(Section 7031.5,Business and � " �.-. •'• •2
Profess�ons Code): � .
� ❑ I,os owner of�he properry,will do the work and rhe M,sc.Conduits 8 ConduUors � '���,��,��8
structure is not intended or oifered for wle(Sect�on Other(See Complate Fee Schedule)_ .
7044,Business and Professions Code). � . . a •7�.']Fj�
CONSTRUCTION LENDING AGENCY O 2� 6�B 4
I hereby affirm that there is a construction lend�ng ogeacy for '
�he performance of the work for whith this permi�is issued PERMIT FEE ��Sub-To1a1) - � .
(Sec.3097,Civ.C.).
� ��/�,-�1�� PIAN CHECKING FEE � - . .
lender's Name� ��y����7p-lf.p�iw^�-� . � '
lender's Address
��I Y lK71,�.LA � �RMIT ISSUING FEE __ '
I certify Ihot I hove read this application and state ihat the TOTAI FEE �3,
pbove informarion is torrecf.I ogree lo comply wilh all CouNy -
ordinances and Srote laws reguloling Electrical wiring,and
hera6y authorize represenlatives of this County to eMer upon � �
�h ove-meniianad pro ariy for inspection purposes. SEE REVERSE POR EXPIANATORV LANGUAGE
'� --1:�-..CK:-l.i-�__ . . .
ignowre of Permit e Date
� . � .•APPkOVAlS DATE � - ..' OWNER•BUILDEP DECLARATION-" ��
- � . . . � SIGNATUR[
� TEMP.POWER POLE � � � I hereby offirm lhat I am e empt from the Contmctor's
� �- � - . � � � license la�N for tho following raa;or (Sactlon T031.5,
UNDERSLABWORK _ _ � � BuslnessandProlesslonsCode):Anydryorcounrywhlch
. ' ROUGN CONDUIT� � �� � reqWres a permlt to consfroct,alfer,improve,demoHsh,
_ �or repafr any�slruc%vrc,prb�to 7is Issvancc, also ro�
WIRING r'�, I � - qulreslheopp6contlorauchpe�mlffoflleaslgnedstoro-
- � FIX7lJRES � ' , ment fhat he Is Iicensad pursuoN fo Iho provlslons o!tho
. Contracfor's L(tenna Law(C6vpler 9(commcndng wilb
"-" POWER AUTHORIZED ' Secllon 7000J ot Dlvls7on 3 olJhe Business and Proles-
slons CodeJ o�thaf fie!s exempf therelrom and�he 6asis
� � - UTILIN GO.NOTIFIED . (or fha alfeged exempilon. Any viofatlon oi Soc�lon
� FINAL P c7 � � 7031.5 by any oppflcan}for o permlt subjecfs the appk-
: Gnfer on �`ranf . : � canf fo a cWll penafty ol no�more Ibon live hundred
-�- �-�NOTES dorra���ssoo�.:
, � � � � �I,as owner af Iho proporty will do the work,ond
� " tho strutlure(s not intended or offerod for salo.
• , . (Sec.704�,Buslrtass and Proless�ons Codo: The Cano-oo-
� - � �for's Licensc Law doos nof apply}o an owner o1 properry
. . . , . wbo bWfds or Improves Ihereon, ond who daos such
' ' '�� work hlm�eB provlded f6of socb Improvomenfs are not
� -- � - � , intended or olfered for sole.If,however,the butlding or
� Improvemont!s sold w/th7n one yeor of rompfc�ion,lhc
� _, � . . , , '� owner•bu(lder will have fhe 6urdrn oi proving fhaf he did
� nof 5ulfd or fmprovc for ihe pwposc of safe.)
� _ :I om exempt under Sec. ,
6 8 P.C.for this reason
Da�e
Owner
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