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_ �WORKERS'COMPENSATIONDECLARATION 76A663 10/87 A�PLIC�TI�IV F�R ELECTRICO�L PERMIT � i
ct-xosc;
I�hereoy affirm that I have a r.ertlficate of consent to sclt insure,
or a cPrtificate t;Workers Cnmpensation�nsurance,or a certified COUNTY OF LOS ANGELES BUI�DING AND SAFETY
� copy thereof(Sec:�3800,tLabC,� � y �1 - �
Polic �t���t1t)��r.�11' LI L�.t-G�:tiv��t.�L=,c--�
Y+ .,ompan� FOR APPLICANT TO FILL IN JOB ��
❑ Certitied co is hereb furnished. EACH N0. FEE ADORess . � w.� ��
. . PY . Y . ,. Neai Residential Bldgs.&Pool y -
t&2 amil S Ft �_.�� $ — $ LOCALtTY� r-
� '�Certifietl copy is filed with the county building inspection Y, a�
NEaR�si
de rtmesk. i ��v- �),,,_}-, Mul�a Ft. � Cftpss 5T.
. Date ���r� Applican��/�"'"j" J rs 7��-'`-�-,�-r-,. �eside ia�l Sw�lmrniny Pools owNER�R
nRnn Nn,UE � . .v
� CERTIFIGATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light_Sw.—. Mai� � w`�� �
- � � COMPENSATION INSUHntvcE nooaess
�� �(This�section neetl not be compieted'rf the work invo4vetl by the First 20 � -
permit is for one�hundretl dollars($100)or lesaj - Total No. Ad<iitional ��T� C_ TeL tl��.��_' �
1 certify that in the pPrformance of the work for which this permit PLAN CHECK
is issued,I shali not employ any person in any manner so as to APP��I�t�Ni
become subject to the Workers'-Compensation Laws. Lghting Fixtures First 20 ADDRESS
Additional
Total No. GTY lel.No.
Date Applicant Fixed Appliances Not Over 1 HP --�------
NOTICE TO APPLICANT: If, aker making this Certificate of PERMIT 1 1�^�
Exemption,you should become subject to the Workers'Compens�tion Range_ Heater_ D.W. _ APPUCaNT �, � ��.(���..L a`J
provisions of the Labor Code,you must forthwith compfy�with such Oven— Dryer_ W.M._ AQDRESSe � �. � ����
. provisions or this permit shall be deemed revoked. . . T _ FAU _ W.H._ � • �
LICENSED CONTRACTORS�ECLARATION � CITY .� ��,�y��, Tel.N �'-�-p'/�
� Hood— Fan _ Qther_ d� �,.�-�J
. �I hereby affirm that I am licensed under proYisions of Chapter 9 . Disp. — ftoom Air Cond _ uCENSE�R �� [�-; aass l`- i �
� (commencir�wtth Section 7000)of Division 3 of the Business and AEG.NUMBER �l� /. � /'��
Professions Gode,and my license is in full force en�effect. DISTRICT'JO. PROC,E:SEfl.[lY r
Power Apparatus 8 Large AppGances
f ��"� �y � Size&Type HP,KW,KVA,or KVAR ����_ p
, license Numberc�� !� � Lic.qass -- j�� � Up to 1 incl. � FINAI �"� - ` V
' (� � �!/.e,��u{._ �����3 Over i to 10 Incl. DATE � � � ��� VALIOATION �
� CoNractor -�^4-�
� � �Date � O�er 10 Io 50 Incl. Q
I am exempt under Sec Over 50 to 100 Inc. i FINAL �9 V
BY W
�. B.&P.C.for this rea5on _ Over 100 �
- . . -- � Service;,Sw6d.,MCC 8 Panel6oarcJs , � - � Z
Date: 0-200 Amp.Under 600 V
. Signature � 201- 1000 Amp.Untler 600 V � ,
� ❑ � � � � � Over 1000 Amp.or Over 600 V
Exemption�for Reg.Maint Eiect
� SINGLE FAMILY Temp.Power Pole&Appurtenances
; HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit �
I hereby aftirm that I am exempt from the Contractor's License Law
for the foilowing reason(Section 7031.5,Business and Professions Additional Sign Branch Circuits .. . .
Code):
Misc.Conduits&Conductors
( ❑ I,as owner of the property,will do the work and the structwe � �� 3 a,��,
� is rrot intendetl or offered for sale(Section 7044,Business Other(See ComPlete Fee Schedule)_ .
� and Professions Code). . , � e m s e m�
iGONSTRUCTION LENDING AGENCY � i � ,i �,� ,7 R
I hereby affirm that there is a construction lendirig agency for the
f performance of the work for which this permit is issued(Sec.3097, pERMff FEE (Sub-Totap x
i Civ.C.l. � � � ��•��=-:
. � PLpN CHECKING FEE Q�,�j-�j 7
� Lender's Name
� - PERMIT ISSUWG FEE
�, Lender's Address �� � �
I certify that I have read this application and state that the a6ove - TOTAL FEE
information is correcf.I agree to comply with rll Couniy ordinances �
and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
operty for inspe.Ction purposes. j
/ /� SEE REVERSE FOR EXPLANATORY LANGl1AGE �,
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