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� WORKERS'COMPENSATIONDECLARATION J6A663 t0i81 qpp�ICATION FOR ELECTRICAL PERMIT � j�
I hereby affirm thot I have a certificate of consent to sel( �CE-806G
insure,or a ce���ficare ol Workers'Compensarion Insurance, i COUNTY OF lOS ANGELES BUILDING AND SAFETY �1
or a certified copy thereof(Sec.3800,Lob.C.) �
POolity No Co ppny BI� � FON ARLICANT TO Flll IN JOB �
Cerlified copy is hereby iurnished. ; New Residenfial Bldgs.8 POols EACH NO. FEE /DDRESS�Z pta0/Z sl�¢Ih6
�rtified topy is filed with ihe county 6uilding inspeo 1 8 2•Family,Sq.FL E — 5 LOCALITY �
tion deporlment.� � . . � Molti-family Sq.Ft. — N[.4RE51
CROSS 5T.
Residentfol Swfmm(ng Pools pWNER OR
DOfe � AppliCan� _ FIRM NAME � �-
� CERTIFtCATE OF EXEMPTION FROM WORKERS' � hwi�
Ootlefs:Rec—Light_Sw._ ADDRES5�2
� '� . COMPENSATION INSURANCE � � � . First 20 � ��� �~ �
(7his iadion naad not 6a complvfed if 1he work fnvolved by To�ol No. Addilional CITY o Tel.No.
th�parmif ts fer en�hundred dollor�(SI00)or I�ss.) .
I certify�hat in the performaoce of the work for which Ihis � � � AaPLIGANTK �` �
permi�is issued,I sholl nof employ any persan in ony manner
so as ro'6emme subject to the Workers'Compensotion Laws. Ligh�ing Fixtures First 20 ADDRES$ �� -
� �� Addifionol � �
, Total No. CITY r.�� - Tel.No. ��
Dale ApplicaN� Fized Appliances No�Over 1 HP PERMrt �
NOTICE TO APPI�CANT: If, afler making this Certifimfe of APPLICANT �
Exemplion, you•should become subjecl�to Ihe Workeri Range_Healer_D.W._
Compensotion provisions of the Labor Code,you mast forth- Oven _Dryer _W.M._ ADDRESS Y,�� W
with comply wilh s�ch piovisions or Ihis parmi� shall be Top —FAU —W.H.— p
deemed revoked. .. �� � Hood _Fan _Other_ �� CIN �NT 0 Tel.No./�6
IICENSED CONTRACTORS DECtARATION LICENSE OR �
I hereby a((irm�hat I am litensed under provisions of Chopfer 9 � -Disp. _Room Air Cond. — REG.NUMBER � Class
(commencing wiih Section 7000)of Division 3 of ihe Business �. DISTRICT N0. � PROCESSED BY
and Professions Code,and my litense is in full force and effect. � � Power Apparatus 8 Large Appliancez . /� y
�1, Size 8 Type HP,KW,KVA,or KVAR � �
License Number.as�l�j.� lic.Class ��'� � FINAL � � �� � � V �
i Up 10 1 Ind.
Comractor���-�O N'Atir!Date Over I�o l0 tncl. OATE � ,y.t�� VALIDATION O
❑ Over 10 to 50 Ind. � � ,
FINAL
I am exempt�nder Sec. Over 50 to 100 Inc. BY 6
8.8P.C.for ihis reason Over 100 w .
. Services,Sw6d.,�MCC 8 Panelboords . �- � . ?
e' 0-200 Amp.Under 600 V
$ignaturn - 201-1000 Amp.Under 600 V - � �
a ' Over 1000 Amp.or Over 600 V �
Exempiion for Reg.Mainl.Elecl. .
� �� SINGLE FAMILY .Temp.Power Po�e 8 Apportenances "3� 5 9'� A .
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit #�,• •'•.•'�
I here6y offirm thol I am eaempt Trom the Controctor i License qdditionnl Sign Branch Circuils � �
Law for Iha follawinp reasan(Section 7031.5, Business and � ' � -1 •�.9 S S I1
Prafessions Code): - ' `"`"
❑ I,os owner of Ihe o ert II do Ihe work and ihe M;sc.Conduits 8 Conduttors � � " � - ���,� �'2�5 Q�
Pr P Y"W� Other See Com lere Fee Schedule_
structure is not iniended or of(ered for sole(Settion . � P .. � � � 0 7,2 2�8 5 -
70G4,Business and Professions Code). � � - �
CONSTRUCTION IENDING AGENCY
I hereby affirm fhot fhere is a consiruclion lending agency for�
�he performance oi Ihe work for which ihis permit is issued PfRMIT FEE (Sub-Total) �.r 6'Q . . .
(Sec.3097,Civ.C.). � � '
PLAN CHECKING FEE �� - � �- � '
Lender i Name �
PERMIT ISSUING FEE . . U �� .
lender's Address �
I cerfify that I have reod this applimlion and sta�e Ihat the TOTAL FEE eZ. �'v .
above info�motion is correct.I agree to comply wiih all Coon�y � '
ordinances ond State laws regolating Electrical wiring,and �
hereby aufhori:e representatives of ihis Coumy to emer upon � � � � � � � . �
the obo -m tioned pe for inspeuion urposes. � ,
� � SEE REVERSE FOR EXPIANATORY LANGUAGE
gnarure of Per �ree Date '
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