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! � WORKERS'CO:NPtN5AT10NDECLARATI'ON � � 76A663�� pPPLICATION FOR ELECTRICAL PERMt_T ��� � � 1 .. � CE-806G(2-801 �` � [ hrrehy aef�rm that r have a certi£icate of consent to self COUNTY OF lOS ANGELES BUILDING AND$AFETY inaure,or a cerhti�ate�of Workers'Comp�nsaPion]nsurance,or � a certi���� (_��.3$00,'� — ---- ��� FOR APPLICANT TO FILL IN Jpg ; Po y o. iJL�mnany EACH NO. FEE ADDRE55 � New Hesidentlal Bldgs.&Pools _ ' � a Certificd copy is herehy furnished. 7&7-Family,Sq.FL y _ � LOCALIYY . �_ I ��i� MUILi-fdmily Sq.Ft. — NEAREST i _ertified copy is filed with the�p unty ilding inspec�on - CROSS ST _._ departmen� /j Residentia�Swimming Pools OWNER OR � / �, r/y F�RMNAME . - '� Date�� � Appticaer� ' Outlets:Rec.�Li9ht_Sw. � qDDRe55 � e (.- � . First 2� ---- E CEKTlFICATE Ob'EXEMPTION FROM W PKS' � To[al No. Aciditianul CITY Tel No �� . ', � . COMPF.?7SATION INSURANC � PLAN CHECK a" } �..� ' APPLICANT � ' � (This secrion nced not be compieted if fhe work involved.� - --- ����— - t by the permit is fox one Imndred dollars ($100) or 1ess.) ' Light�ng Pixtures First 20 aooaEsS � �- Additional — -�- �! '�., Total No. CITY Tel No. . � � �7 certify thr�t in the performxnce of the work f"or which tiiis '� Fixed Appllances Not Over 1 HP _._._.. O � permit u issued,I shall noY empinq any pecson in xny manner ' PERMIT � . i3S 1 so as to become n�b;ect to!he R'orl:ers':,'ompensatian Lmvs. � Range_Heate[,_D.W._ APPLICANT .,__ _ � . } � Oven _Dryer_W.M..� ADDRESS � � � ; 1 , �_ �Date ApplicanL Top _FAU —W.H._ CITY ����Qt"ei No. ._...iq_ �� - Hood—Fan .r Other— � �2_ :' NOTIC��TO APPLICANI�=1f,aftcr making this Certificaec oi �isp. _ftoom Air Cond.� __ ��CENSE OR � lixemption, you ahould Uecome subject to tlie Wurkcrs' . REG.NUMBER lass � Compensetion provisi�ns oi the Labor Code,you mUst furtli- pOwer AppdratuS&Larye ApplianCes DISTRICT NO. PROCESSEO V � u�ith comply with such provisions or ±his pecmit n}�nll be -. Size&TYPP�P,KW,KVA,or KVAR � � deemed revoked. � '�'�%% � �.,,r�� (L "' � � � UP to 7 IncL . ... . �•. ."'�,`"� - —"' FINAL � �Over�to 701nct. oaTe ���t�� VALlDATiON �� - LICF.NSF,D CONTRACTORS PECLARATLbN Over 10 Ta 50 inci. �� . FINAL � I hcreby affirrn that I am licensed under provis�ons of Chapter ` Over 50 to 700 tnc. B�, � . 9 (�onxmeocing with Section 7U00)of Di��sion 3 of ihe Husi- Over 100 ��/���G�.��� � ness and Professions.Code,and nty L�cense is ia futl force and � effec[. Services � � � �✓Z'1./7�t� �� Q-200 AmP.Under 600 V� .—_— .._... __. License Number Lic.C�ess � s�A,���_�•� � i 7 2D1-1000 Amp.Under 600 V CuntractorE�`/—:L=— Date�� �, Over 70Q0 Amp.or Over 600 V �� . � HOMF.0�4'NER-HUIt,DER]?ECLhRATION -Temp.Power Pole&Appurtenanaes _ I I hereby a[f'um that I am exempt from the ConYracTor'a Sign witb Qne Branch Circuit � License Law fnr the followin&�eason (Section 7031.5, Busi- fldditiona{S�gn Branch Circuits --- _ nees anp Yrofessions Cucle): �, � Misr,.Conduits&Conductors ---- °��.� ,���-'�' � � i, as owner of tlie property,will do the work and the DCher(See Comple{e Fee SchedWel— e� - � structure is not itttended ur offered for sale (Section ^e �.s ° � 7044,Rusiness and Professions Code). . .. j CONS'IKUC7'ION LENDiNG AGFSCY ��-- 7 '�� ����� � ( 7 hereby affirm thnt there is a constcuchon iending xgency � � 9 fm the perfarmance of the work far whieh thu permit �s pERMIT FEE ISub-Total) r , - '�'�`� n` issued{Sec.3097,Civ.C.). ��' � � � ��� 4 Lcndcr's Name + i�.(��.�'^�� � 1 PLAN CHECKING FEE (One-Fourtfi Permit Fee) _ � Lender's Address _... � , t` � ; PERMlT ISSUING FEE , J I certify that I have read th(s npplication and state that the �TOTAL FEE �]��' � aba�c information is coriect.1 agrec to comply with al!CountY -- ��"� i ordinanees and State laws cegulati��g Electrical wiring, and - f herehy xuthorize representatives of this Coi�nty to enter upon ' the ab -mentio raVerty for"nspectimi purposes. 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