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WORKERS'COMPENSATIONDECIARATION�� 76A663 �o,e� APPLICATION FOR ELECTRICAL PERMIT
I hereby af(irm thot I hove a cerfificote of consent fo self CE�B06G �
insure,or a cerrificare of Workers'Compensalion Insvrance, COUNTY OF LOS ANGElES BUIIDING AND SAFEiY
or a cert�fied copy ihereof(Sec.3800,Lob.C. �3—$'7
POolicy NoW�.tr����om n I � � .
� Y FOR APVIICANT TO Fllt IN !OB
Cer�ified copy is hereby furnished. New Residentlal Bldgs.g7�P�o s� EACH � NO. FfE ADORE55 3
� Ce�tified copy is filed wi�h the coonry boilding inspec- �&2-Family,Sq.Ft.J112L_ E — E LOCALITY � '�' .
tion deportmenl. Mulfi•fomily$q.FI. — NEAREST ` . �
7�'Di� �.S.�� Residentiol Swimming Pools � OWNER OR `
Dale AppliConl . . FIRMNAME �c] �• I
CERTIF�CATE OF EXEMPTION FROM WORKERS' � � Mnit
� � COMPENSAT�ON INSURANCE -�. - OuNets:Ret�liqht_�Sw. qDDRESS (J� $
�hlt s�dlon na�d not 6�com IN�d if thb work invoH�d b First 20 ,
( P Y Total No.�_ Additional CITY � rat.No. _6
ffi�p�rm�t is far on�hundrad dollvrs{5100)or Isfs.) .
I certify ihot in Ihe performonce of Ihe work"for whith ihis ' � qppNK,�,qHN7K � �
�pe�mi�is issued,I sholl not employ ony person in any monnei .
so as to become subjett to�he Workers'Compensation Lows. Lighting Fiztures Fi�st 40 ADDRESS �� � �
� ' � � Torol No. Addilional
Date opplitont � � CITY Tel.No.
NOiICE TO APPIICANT: IF, affer making this Gertifimte of Fixed Appliances Not Over 1 HP pERM1T /��
Ezemption, you should�become subject �0 1he Workers' Range_Heoler_D.W._ APPIiCAM f_.I� ,S.rj S�A L
Compensoilon provisions of the labor Code,you musl ionh- Oven _Dryer _W.M.— ADDRE55 G'QM
wi�h comply wirh such provisions or this permit shall be Top _FAU —W.H.—
deemed revoked. � � � CITY Q Tel.No. ]
LKENSEU CONTRACTORS DECLARATION , Hood _Fan _Other� � ��
Disp. _Room Air Cond.�_ 3 LICENSE OR , .Clasa,C— Q
I heraby affirm thal I am litensed under povisiona of Ghopler 9 �7� REG.NUMBER � . .
(commencing with Secfion 7000)af Division 3 of Ihe B�siness �Ar-7K t ��yl/� Q�cne/', DISTRICT NO. PROCESSED BY
ond Professions Code,and my license is in full force and eHect ��+er.q,paratus �arge A pliances . .. � _ �
, , ' . Size 8 Type HP,KW,KVA,or KVAR' �
Litense Nvmber Lic.Ciass � � � Up to 1 Incl. � FINAL � � � � V
Controttor Date Over 1 to 101nd. DATE 1�;�/,d� VALIDATION p
❑ . , Over 10 l0 50 Ind. V
FINAL
I am eMemp�under Sec.� Over 5010 100 Inc. BY wa
B.BP.C.ior�his reason Over 100 y
. . . , . . _ . Services.Swbd..MCC 8 Panelboards ' . . ► . . . - i:�,.��.�'j A Z .
Date: � 0-200 Amp.Under 600 V
Signatu�e � 201-1000 AmP.Under 600 V � . . $j •:e :. .•2
❑ Over 1000 AmP.or Over 60p V . . . . � °.•.?��(�. . . ..
Exemplion for Reg.Moint.Elect. � ��- �-� ��� -�� � �� �� ��
. . .3Q24�
-- � $INGIE PAMRY iemp.Power Pole 8 Appu��enantes . `�$.Q S—8 7
HOME OWNER-BUIIDER DECLARAT�ON Siqn wi�h One Branch Circuit -
I hereby a((irm�hat I am exempt from�he Canhac�or's ticense A��������I S„��g.ertch Circui!s �
law for the foliowing�eason(SeUion 7031.5,Business and - � - ''� � ���� � � � -
Professions Code): �
❑ I,as owner of Ihe prope�ly,will do the work ond Ihe Misa Conduits 8 Condoctors-�� ' � � � — - �
strocrure is not imended or aifered for sale(Setlion _ Olher(See Complefe Fee Schedole)_ ►
704A,8usiness and 7rofessions Code). , ' � � � �
CONSTRl1CTION IENDING AGENCY - � � � �� � �
I hereby affirm�hat there is a construction lending agenty for
� ihe performonce of ihe work for which ihis permit is iswed PERMIT PEE � - - �� � (Sub•Total)� � .� � . .. . .
(Sec.3097,Civ.C.).
� � PLAN CHECKING FEE - . _. . .. �
Lender's Name � �
._. PERMIT ISSUING FEE . . _ . '
lender's Address � �� �
I certify ihof I have�eod ihh opplimtion and sia�a that the TOTAL FEE
obove in(ormation is torreU.I agree�o comply wiih oll Counry � � �� � ��
ordinantes and Slate lows regubting EleUriml wiring,and , , �
.. . ...... _... . . _ ..
hereby authaize representatives of this County to enter upon � � � " " -� �-- � �
the o6ove-mentfoned property Tor inspection purposes. SEE REVERSE FOR EI(PIANATORY IANGUAGE
�'1�,� � �'�� 7-34-�''7
Signarore of Permiuee Date. �
J.
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