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WORKERS'COMPENSATION DECtARATION ��,�,81� APPUCATION FOR ELECTRICAL PERMIT
I hereby offirm Ihal I hove o ter�ificofe of consent to self
insvre,or o camiko+e of Wo�kars'Compensation Insu�a�ce, COUNTY OF LOS ANGElES BUILDING AND SAFETY
or a�CHiuo,�copy thereof Lab.C.)
ti CS ',�I � .y� 1,1
Poli No.__L��m y��4�KN� FORIIPPLIGMTOFlIIIN JOB ` f� A«1� ��y✓ �
Cerlified copy is hereby furnished. New Residential Bldgs.&Pools EACM NO. FEE ADDRESS
Certified copy is filed with Ihe coun�y ilding in pet• �g 2-Family,Sq.FI. 5 — E �OCALITY -
tion depo�m nL MvNi-fumily Sq.F. � — NEn�iFST
Residenlial Swimming P ol5 OWNER OR (�f�1
Dnte Appliconf ' FIRMNAME /�daG-V OU � �
CERTIF CATE OF EXEMPT ROM WORKERS' M/+��
COMPENSATIO NSURANCE Outleta:���Light Sw. AODRE55 I {
First 40 �
(Thts�atfion nwd nof bs eomplN�d�f eh�work inrohed by ,70�01 No.� Addifionol � CITY Tel.No.
!h�p�rmil t�for on�6�ndred dollon(5100)o�I�ss.)
PIAN CHKK
I te��ify that in Ihe performonce of the work For which ihis APPtKANT
permit is issued,I sholi nol employ any perwn in ony manner
so as io bacome subject to�he Workers'Compenwtion Laws. Ligh�ing Fivrores First 20 ADDRESS �
� � � Totol No.� Additional CITY � Tel.No.
Da�e �pp�kont Fized Applionces Nol Over 1 HP' vERhvT
NOTICE TO APPLICANT: If, ofter moking thiz Ce.�ificate of � " • AwuG4NT �A N.✓C� -
Exemp�ion, you should become s�b�ect to �he Workers' Range�Heater_D.W.—
Compensa�ion provisions of the Lobor Code,you mvsl for�h• Oven _Dryer,._W.M.._... ADDRESS g �/�r vC• .
. witb comply wirh such provisions or this permit shall 6e .Top _.FAU �—W.H._ CITY J LL 6 Tel:No. Q_
deemedrevoked. � � �. ' SO.(/✓. -
Hood _fan ,_O�her_
LICENSED CONTRAC70RS DECLARATION � LiCENSE OR �
I hereby affi�m thal I am licensed under provisions of Chaplar 9 Disp. _Room Air Cond. — REG.NUMBER �00 �2 Class.a_�
(commencing with Sec�ion 7000)of Division 9 of the Businau � DISTRICT NO. PROCESS D BY ,
Power Appamlus 8 Large Appliances � >'
and Professions Code,and my license is in full force and effect. . � � � � � " ""-" �� � ' y �
� �� � /�}� /_ �Sixe 8 Type HP,KW,KVA,or KVAR�. O -`1 V
License Nu �v��v Lia Class� FINAL ( � �
Up fo 1 Intl,
Over.l l0 10 Intl. DATE � �a 1 ➢� VAli0AT10N Q
Contratl �te'� Over IO l0 50 IncL FWAI V
.❑ I am exempt vnder Sec. Over 5p to 100 Inc. BY nn . W
Ovar 100 � I�' V l� ��J � •
B.BP.C.for this�eason ' . � .
� Services,Swbd.,MCC 8 Panelboords � �� . Z .
Da1e: 0-200 Amp.Under 600 V
Signoture 101-1000 Amp.Under 6W V � �
❑ � Over 1000 AmP.or Over 600 V . . .
Ezempiion for Reg.Moin�.Elec1.
S{NGIE FAMIIY � Temp.Power Pole 8 Appurtonantes . .
HOME OWNER-BUILDER DECLARATION � �e� 7�•2 A
Sign wilh One Bronch Circuit . . .
I hereby affirm that I am exempl from the Camrac�or's License Additionol Sign&ancb Circuits ri�4�� ��•.�����
Law for�he following reason($ec�ion 7031.5,Business and .
vrofessions Code): ( • •z fi 5 0
❑ I,as owner of the property,will do�he work and�he Misc Conduits 8 Conductors � � . �- - - .
stroclure is not intended or offered{or sale(Section . O�her(See Camplete Fee$cheduleJ_ ► •:• •2 5 5 0�
' 70d4,Business and Professions Code). �
�CONSTR�CTION LfNDiNG AGEPoCY . O Z 2 J�8�l
I here6y oNirm thal there is a construUion lending egency for . .
�he performonce of tfie work for which tbis permit ii iswed pERMIT FEE � . � � �Sub•Totol) � V � � '
(Sec.3097,Civ.C.�. � �
%AN CHKKfNG FEE - � � .-.
lender's Name - . �
PERMIT ISSUING FEE . � O O � .
Lender's Address ' - � �
I ceriify ihat I have reod Ihis applicotion and sta�e that�he TOTAL FEE .s�! '
obove informotion is correN.I ogree ro comply with oll Counry �
ordinances and State laws re9ulaling Electricol wiring,and
hera6y oui rize repre ntotives of this Coun�y to eNer opon ! � � � -
the abo -i lioned r perty for inspec�ion purposes.
� SEE REYERSE FOR EXPLANATORY IANGUAGE
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