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WORKERS'COMPENSATION DECLARATION 76A667 ,o�e, APPLICATION FOR ELECTRIC.AL PERMIT
I here6y affirm thal I hove o cerfificote of mnsent lo self CE-806G .
insure,or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELE$ BUILDING AND SAFETY !
or a cerlified copy thereof(Sec.3800,Lob.C.) �
P❑ol�i[y NO. � COmpony FOR APPIICANT TO FlLL IN JOB G
Certified co is hereb furnished. EACH NO. FEE ADDRE55 —L 7 C�
PY Y New Residentiol Bldgs.8 Pools
� Ceriified copy is filed wiih ihe co�niy 6�ilding inspec- �g 2-Family,Sq.Ft. E — E LOCALITY q(,,,u '"r L
�ian department. � Mul�i-family Sq.FI. — NEnReST � \'
Resideniial Swimming Pools �R�SSST. �y
Dale � Appiicant FlRMNAME L��,E O . �I'^E vE
CERTIFICATE OF EXEMPTION FROM WORKERS' � ,� � �� 6 .F� T I{ E IZ
Outlels:Rec_Light Sw._
COMPENSATION INSURANCE First 20 � � ADDRE55
(This�ecfion naed no1 be complal�d if fh�werk involvad by 7oial No.� Additionol CITY (, u"' Tel.No. 5' .(p
ihe permil ts fo�ona hundrad dolinrs(SI00)or lass.) � plqN CHeCK ^L , E Q s C Z
I terlify 1ho1 in the periormonce of the work for whith this APPLIGANT �-T
permit is iss�ed,I shall nal employ any person in ony monner �
so as to batome subject to ihe Warkeri Compensation Laws. Lighting Fi.Wres First 20 ADDRESS
� To�al No._y� � Additional
CITY ��,�uu Tel.No. S IF.�J
Date applicant � Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT: If, afler moking ihis Certificale of APPtICANT � � � �
Exemption, you�should 6ecome�subject to the Workers' Ronge_.Heater_D.W._
Compensation pravisions of�he labor Code,you must forth- Oven _Dryer _W.M._ ADDRE55 l� ( <
with comply with such provisions or this permit sholl be _7op _FAU _W.H.—
deemed revoked. Hood _Fan _Other_ CITY �� iel.No: ��-
LICENSED CONTRACTORS DECLARATIDN UCENSE OR.
I hereby offirm Iho1 I am licensed under provisioni of Chapter 9 Disp. _Room Air Gond. — REG.NUMBER ����-
(commencing with Seclion 7000)of Division 3 of the Business power Apporo�os 8 Large Appliances DISTRICT NO. � PR ED BY �,
-ond Professions Code,and my license is in full forte and effecl. d
Size 8 Type HP,KW,KVA,or KVAR Q
License N�mber Lic.C�ass Up l0 1 Incl. FINAL V
� Over 1 to 101nd. DATE ��`�^� AUDATION Q
Controctor � Date Over 10 to 50 Ind. � �
FINAI / ~
❑ I om exempl under Sec Over 50�0 100 Inc. BY ���✓j/�/ , _ , 6
B.BP.C.for this reoson Over 700 f '"A N
Servires,Sw6d:,MCC 8 Panelboards . Z
Dare: 0-200 Amp.Under 6W V :s G 5 Q�l�� -_
Signature 201-1000 Amp.Under 600 V � ' � -
��_�•�• • e •`�
❑ - Over 1000 Amp.or Over 600 V �
'Exemption for Reg.MainL Elect. � � �..�.���
SINGLE FAMILY Temp.Power Pole 8 Appur�enonces �� G J C�
HOME OWNER-BUIIDER DEQARATION Sign with One Branth G�cui� ' '
I hereby af(irm thot I om eaemp7 from the Controcloi s litense naa,,;�r.�!Sign 9rcn;h Circui's
law ior the following reason(Section 703L5,Business ond -U b U�—N z
_Proiessions Code): �
�+� Misc.Conduits 8 Conductors
jQl I,os owner of fhe properry,will do ihe work and the
struc�ure is not inrended or of(ered for sale (Section Other(See Complete Fee Schedule)_ ►
7044,Bosiness and Pro(essions Code). � - � --
CONSTRUCTION LENDING AGENCY . .
I hereby aifirm�hat there is a consnuction lending ogenty for�
fhe pe�formonce of Ihe work ior whlch lhis permit is i55oed - pERMIT FEE � (Sub•Tofal) � . .
��Sec.3097,Civ.C.). .
PLAN CHfCKING FEE . .
Lender's Name � . � p ,
PERMIT ISSUING FEE �
lender's Address � -
I ce.tify rhar I hove read rhis opplication ond s+are that rhe TOTAI FEE. � G �J�
obove informorion is correct.I ogiee to comply wi�h all County � �� "
ordinontes ond Sta�e laws regolating Electrical wiring,ond - � . .
hereby outhoriza representarives of ihis Couniy to enrer upon �
th abo e-meniio�3 d p openy ior inspeciion purposes. SEE REYERSE FOR EXPLANATORY LANGUAGE
A - 9�—/—�'3
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