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I WORKER$'COMPENSATION DECLARATIDN 76� ,�,81 APPliCAT10iV �OR ELEC3RiCAL P�RMIT �
� I hereby offirm ihat I hove a certifimte of consent-ro seff CEA06G
j insure,or a cenificate of Workers'Compenwtion Insurance, COUNTY flF LOS ANGELES BUILDING AND SAfETY
or o certified copy ihereof(Sec.3800,tab.C.)
1 WCWJ�S� t"IEST AMERICAN INS. fORAPPIICANTTOFILLIN 108
Policy No. ompon
! ❑ Certified copy is here6y furnished. New Residential Bldgs.8 Pools EACH NO. FEE ADORE55
� �� Cer�ified copy is filed with�he counry 6uilding inspec- �&Z-Family,Sq.F�. jl}��a_ E _ a ��A��TM �
� tion deparimenf. Mulfi-family Sq.F. NEAREST �
CRO55 ST.
Date Appli[ant Residentiol Swimming Pools OWNER O
! . FIRMNAM�OCAW�D GROUP
� CERTIFICATEOF�EXEMPTIONFROMWORKERS' 2 1 1 .]5 3, D ��� 0 TOMM S COUNTRY RD�
COMPEIVSATiON iNSURANCE� OuNets:Rec_light_Sw._ A�DRE55
� iTh(s section need not be com lefed if fhe work involved b first 20 55$-9Q72
he permil i�for one bvndrcd dollan(5100)m lees.) Y Total No. Add�t�onol arvORANGE 92668 Tel.N
� I certify thot in ihe performance ofihe�work for which this pppNj�CqMK
permit is issued,1 shall noi employ any person in any ma�ner
so as to become subject to�fie Workers'Compensation Laws. Lighting Fixtures- First 20 ADDRE55
� . Additional
Total No. [ITY Tel.No.
� �ate ApP���a�� Fixed Appliances Not Over 1 HP pERMIT
� jTICE TO APPLICANT: If, after moking ihis Certifimfe of aPaicnNTVICTOR �L.ECTRTC, �NC.
�rnption, you should become sobject to the Workers' Range_Heater.�D.W. _
�ompensation provisions of�he labor Code,you must forth- Oven _Dryer _W.M.— AO�RE55 ��1
� winc �omp�y with such provisions or �his permit sha�l be Top _FAU —W.H._— CITY Tel.No
deemed revoked. Hood _Fan _Other_ —
LICENSED CONTRACTORS DECLARATlON Di _Room Air Cond. — �KENSE R, Class.
1 hereby affi�m that I am ticensed�nder p�ovisions of Chopter 9 �� REG.NUMdf�}�1�5 C-1
(commencing with Saction 7900)of Division 3 of the 6usiness DISTRICT NO. PROCE$$E 8Y
and Professions Code,and my Iicense is in full face and effeci, Pa�"'er Apparatus 8 Large Appliances /� ��J O
- Size 8 Type HP,KW,KVA,or KVAR
License Number Lic.Class P FINAL 9;'��:.� V
U to 1 Intl. pA� � � _ ,- � �
Over 1 to l0 ind. •7 �� .� VALIDATION
ConrroUor Dme p U
❑ Over 10�0 501nd. '.-.~: F
I om exempt�nder Sec. Over 50 to 100 Inc. 8 �� W
� �Ve�100 � 1'�'`h� M
B.BP.C.fo�ihis reoson Z
Date: Services,Swbd.,MCC 8 Panelhoaids �
0-2U0 Amp.Under 600 V
� Signature �Ol-�000 Amp.Under 600 V
1 ❑ _ � Over 1000 Amp.or Over 600 V z 1 7 3 6 A
� Exemption for Reg.MainL Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances �� � � ' �2
k HOME OWNER-BU�lOER DECiARA710N
Sign with One 8ranch Circuit � � �7��-�
�by affirm�hat I am exempt from the Contractor's License
r Additional Sign Branch Circoirs
L. -for the following reoson{Settion 7031.5, Business ond � � �•�2 2 2�
Professions Code): �
❑ I,as owoer of the property,wi�l do the work and�he Misc.Conduits 8 Conductors �2 2,��8�l '
slruc�ure is not intended or affered for saie($ettion ��her(See Complete Fee Schedule)_ �
7044,Business and Professions Code).
CONSTRUCTION LEND�NG AGENCY
I hereby affirm tFat ihere is a consfruction lending agency fof
I ihe perfo�mance of the wo�k for which this permit is issued pERM1T fEE (Sub-Total) [j j �
(Sec.3097,Civ.C.). �
PL4N CHECKING PEE
lender's Name
PERMIT ISSUING FEE �
Lender's Address -
i rertify�ha1 1 have�a�l this appl"cation and state�hat�he TOTAL FEE 72,Q
above informa�ion is c ec�.I a .to mmply with ail County
ordinances and St ,la gul ting Eiettrical wiring,and .
hereby, Lorixe reB[et�tatives of ih" ounty to enter upon
%�aG e-me iefied pr erty f nspe ion p�� SfE REVERSE FOR EXPLANATORY LANGUAGE
� �'
Signa e of Perm� e �Date
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