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WORKERS'COMPENSATIONDECLARATION �6,� �o,e, � qpp��CATiON FOR ELECTRICAL PERMIT � �
I hereby affirm fhat I heve o cerlificole of consent to self �'B�
insu�e,or a certiiicate of Workers'Compensaiion Insurance, COUNTY OF LOS ANGELE$ BUILDING AND SAFETY
o�o certifi�d cop�y�Ihereof(Sec.3800,�b.�C. � r
Policy No. ``+t� rCompony- FOR AP►LICANT Tp FILL IN J08 �
� Certified topy iz hereby furnished. � New Residenliol Bldgs.8 Pools EACH NO. FEE ADDRF55 � , f � !, - ' ���
� �Certified copy is filed wi�h the tounty 6uilding inspec- 1 8 2-Fomily,$q.Ff. t — E LOCALIN ��' -
NfAREST
lion deparlment. M�IIi•{omily$q.Ft. — � /
CRQSS ST.� .L � C7�' /
y Residenfiol Swimming Pools
Do1e ` — Applicanl . . OWNER OR
FIRM NAME
CERTIFICATE OF EXEMPTION FROM VJ RKERS' Ourlets:Ret�tight_Sw..�
COMPENSATION INSURANCE � F'g'p � �D qpDIRE55 '
(Thi�tetllon nwd no16�eomplsf�d iF rha work tnvoWed b � pp CITY . . Tel.No.
Ihe parmif is for en�h�ndr�d dollnrs(SI00)er le�s.) � Total No. -� . Additional �
PLAN CHEIX
I certify thol in�he performance of Ibe work for whith this . A����A� �
permit is issued,1 sholl not employ any peraon in any monner .
so as lo become subjetf to the Workers'vCompenwlion Lows. Li9hting Fixt�r First 20 ' ADDRE55 �
Torol No.� Addifional
�r- ' CITY Tel.No. �
Dote f�— / ��opplicant Fixed Applionces Not Over 1 HP PERraiT T
- NOTICE TO APPLICANT: IF, after making thi Certifi e of APMICANT E�' ,�� � /
Exemption, you should become subjecl ta the Workeri Range_Heote�_D.W.— ,
Compensation provisions of�he Lobor Code,you must forth- Oven _Dryer _W.M._ ADDRESS � ,�^ '� � ��'
wifh tomply with suth provisions or ihis permit shall be Top _FAU _W.H.—
deemed�evoked. � Hood _Fdn _Other— CITY - � ' { ' -Tel.No. C�. 5'�
LICENSED CONTRACTORS DECLARATION � uCFNSe Ort � �
. I hereby offirm Ihol I am licensed under provisions of Chapter 9 Disp. _Room Air Cond. — REG.NUMBER � Closs. `°
(commencing wilh Section 7000)of Division 3 of Ihe Businass powar Apporot�s 8 Lorge Appliances DISTRICT NO. PROCESSED �
ond Professions Code,and my license is in full force ond eHect. . . . � . / . 6 .
�!^h ,/� Size 8 Type HP,KW,KVA,or KVAR� �� ���`�'
License Num6e b J1 'Y- lic.Closs� � � „ �
Up Io 1 Ind. FINAL V
- n C � �� ` " Over I to 10 Ind. DATE � � 8� � VALIDATION � �
Contractor - Da�e G � I Over 10 to 50 Incl. �
� FINAL V
I om ezempt�nder Sec. Over 50�a 100 Inc. gY ui
B.SP.C.torth�s.eason Over 100 - -- �- N
► 2
- � Date: Services,Swbd.,MCC 8 Panelboards - � . . .
0-2W Amp.Under 600 V � �
Signo�ure 401-1000 Amp.Under 600 V - - �
❑ Over 1000 Amp,or Over 60D V
E.emp�ion for Reg.Moin�.Eiett.
SINGLE FAMILY Temp.Power Pole 8 Appurtenantes �D 91�9 A
HOME OWNER-BUIIDER DECLARATION Sign with One Bronth Cirtuit
I hereby oHirm tha�I am exempt from�he Contracror's litense #� • • i •`�
Low for iha fnlinwinp.Pnso�Ke.r�nn 703!.5,a��eices:c.^.d Addilional Sign Branch Circuits . .
Professions CodeJ: � • �6�Q O
❑ I,as owner of�he property,will do ihe work a�d the M,sc Condui�s 8 Conductors � � - �� �
strocture is not iniended or offered for sole(Sec�ion Orher(See Complele Fee Schedule)_ , •.•�•6 Q�Q i�
-7044,Business and Professions Code). - O 1.O 9"8�l
CONSTRUCTION IENDING AGENCY ..
1 hereby offirm that�here is a consfrocfion lending ogenty for - � . �
the performance of the work for which Ihis permit is issued pERMIT FEE - (Sub-Totol) s� � . .
(Sec.3097.Civ.C.). � . � � �
s
PLAN CHECKING FEE � �
Lender's Nome � � --�� �
PERMIT ISSUING FEE rU �
lender's Address
I certify ihaf 1 hove read this applica�ion and sta�e�hot ihe 70TAL FEE � ���yp �
obo4e informv��on is correct.I agree ro comply with all Coumy � �
ordinonces and Slate lows reguloling Elecfrical wiring,ond . � �
hereby authorize representetives of Ihis CouNy to enrer upon � �
the obo� rner+uo�ed rope�ry for inspetrion purposes. SEE REVERSE FOR EXPIANATORY IANGIJAGE
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