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WO!?KERS'COMGENSATION DECIARAT�ON �'16A663 �o�e, APPLICATION FOR ELECTRICAL PERMIT � �
I he��46y bf(irm ihat I have o certificate of consent to self CE-906G
insure,or a tertificate of Workers'Compensa�ion Insurance, COUNTY OF LOS ANGELES BUILDII�G A�ID$AFETY
or a cerrified copy thereo((Sec.3900,Lab .J
Q�� O D O�ompony FOR APPLICAHT TO FI�L IN JOB
Certified copy is hereby furnished. EACH NO. FEE , A�DRESS
New Resident�al Bldgs.8 Pools
� Cerlilied copy is filed wifh Ihe county building inspec- 1 8 2-Fomily,Sq.Ft. S � — f LOCALITY �A �Q •
tion deportment. Multi-fomily Sq.Ft. — NEnRESi
y Residenfial Swimming Pools. CROSS ST. rV
/Da�e�Applitan� f � OWNEB OR .
FIRM NP.ME
CERTIFICATE OF EXEMP 10 OM WORKERS' Ou�lets:Rec_Light_Sw._ �'10'��
COMPENSATI SURANCE . F.5 p a0DRE55
(Thl�sacTlon nsed not h�complat�d if th�work lnvolvad by Totol No. � �n' Tel.No.
Ih�p�rmif ft(or on�hundrod dollan(SI00�or bu.� �- Addi�ionol �i .�
I cerlify thol in�he performance oi Ihe work for which this qppNl�qNTK �
permilis issued,I shall nof employ ony person in any rimanner
so as to 6ecome subject to the Workers'Compensotion laws. Li9hting Fixtures First 20 ADDRESS.--�
Total No. Additional
CIiY � Tel.No.
�ate opplimnt Fized Appliances Not Over 1 HP PERMrt
NOTICE TO APPLICANT: If, afrer making this Certiiicate of APPLICANT, �i t N
Fzemption, you zhould become subject to �he Workeri Range_Heoter_D.W._ -
Compensaiion provisions of�he Lobor Code,you mus�farth- Oven _Dryer _W.M., ADDRE55 9 /,� �/
ith comply with such provisions o� �his permil sholl be iop —FAU —W.H:� q�
deemed revoked. Hood _Fan _Olher_ GTY Q p�fF+ � P. CA Tel.No. . �
-- LICENSED CONTRACTORS DECLARATION uCENSE OR
I 6ereby aHirm�hot I em Ifcensed under provisions of Chapler 9 Disp. _Room Air Cond. — REG.NUMBER< < <�°s5. �,; �
(mmmencing with Section 70W)of Division 3 af ihe Businets .. __ . . . DISTRICT NO. � PROCESSED BY Q ��
ond Pro/essions Code,and my licensa is in(uli force and effecL P�wer Apporotus&large�Applioncas� h .
Size 8 Typa HP,KW,KVA,or KVAR- /V V
�License Number ��� �/�� lic.Class� �FINAL - �
�, Up to 1 Incl. Q
Contrador-��� �'�£/� Ar. . �i>/ Over 1 ro IOlnd. DATE 22��f�1.,Qf - VALIDATION F"'
CJ !i w
❑ Date / L� Over 10 l0 50 IntL FIN � '�,
�am exempt under Sec. Over 50 to I00 Inc. BY �;r6� � n-�
.`.Oaer 10p V \/�• �
8.8P.C.for fhis.eason Z I
Serviros,Swbd.,MCC�B-Ponelboards � �
��e' 0-200 Amp.Undar 600 V .
Signa�ore A Z01-1000 Amp.Under 600 V �
❑ Over 1000 Amp.or Over 600 V .
Eremplio eg.Moint.Elect. ,.;� 1 7,Jt A .
SINGLE FAMILY Temp.Power Pole 8 Apporlenonces � �
HOME OWNER-BUIIDER DECLARATION Sign wi�h One Branch Circuit �}e • • e i 2
I hereby offirm ihot I om ezempt from�he Contmctn.i Uce�se Additional Si n 8ronch Circuils �
low for the fo�lowing reason(Sectian 7031.5, Business ond 9 � • "2 rJ Jr Q
Professions Code):
� M,sa Conduits 8 Conducrors ' �°�.a�Q U
�,as owner of Ihe properly,will do�he work and the .
struUure is not in�ended or oifered for sale(Sec�ion O�her(See Complete Fee Schedule)_ ► ���,f?�8 6
70d4,Business and Professions Code).
�CONSTRUCTION tENDiNG AGENCY -
I hereby af(irm thot ihere is a mnslruction lending agency for �
the performance of�he work for which fhis permit is issued � pERM1T FEE (Sub•Tofol) �
(Sec.3097,Civ.C.).
� PLAN CHECKING FEE � " �
Lender i Name .
PERMIT ISSUING fEE ' - Q 'L�
lender's Address �1�
I certify thot I hove read fhis applicalion ond state that Ihe TOTAL FEE �^1-
obove informa�ion is correct.I agiee�o mmply with all County
ordinonces and Stare laws regulating Electriml wiring,ond . � �
hereby outhorize represen�otives of th� uMy to en�er opon �.
Ihe above- ntioned propert forin ion purposez � . .
SEE REVERSE FOR EXPLANATORY LANGUAGE
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