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� WORKERS'COMPENSATION DECLARATION 76.4663 t0ie� APPLfCATIOf!! EQ� �t�CTRiCl4! PERM{T �
{ I here6y aff��m that 1 have a cer�ifim�e of consent�o self CE-806G
iinsure,a�a cerrificate of Workers'Compensation Insurance, COUNTY Of LOS ANGELES HUILDING AND SAFETY
( or 6 certified copy�hereof(Sec.3800,Lab.C.)
Policy NeC�.SHSIS7�.Compony INA FOR APPLICANTTO FILL IN JOB
f � Ceriified co is hereb furnished. EACH NO. FEE ADDR I+Ot 9 5 Lisa COUIC
f PY Y New ResideNiai Bldgs.&Pools LOCA ITY
1 � Certified copy ie filed wilh the county building inspec- 1 &2-Family,Sq.Ft. LSG = S 5
� �ion depariment. Mulli-family Sq.Ft. NEARES
A � 86 u n Residentiol Swimming Pools OWNE OR
Date � � Applicanf T McGee Slectric FIRM NAME A[laCll GI •
tERTIfICATE OF EXEMPTIpN fROM WORKERS' MAII
� COMPENSATION INSURANCf Outlets:Rec—Ligh�_Sw._ qoDRE55 1074 Park View Dr.
- ihir sseffer-eard�nei$e 2em tNeQ t11he work i�velved 6 First 20
�a psrmiT is for one Aundrsd dollms(SI00)or le�s.) y Total No. Additional CITY a Tei.No. g67-9541
1 1 cereify that in the performance oi�he work for whith�his pppNj�N�
permii is issued,I shall not employ ony person in ony manner
� so os fo become su6ject to the Workeri Compenwfion Laws. ��9hting Fixtures First ZO ADDRE55
Additionol
Total No. CITY Tel.No.
f e AppNcant fi.ad Appliances Not Over 1 HP 7ERMIT '�
� tv.,��CE TO APPLICANT: if, afte. making �his Cenificme of APPUCANT �"r�� McGee Electric, YIIC.
Exemption, yo� sho�ld become subjecl to �he Workers' Ranga_Heater_D.W.�
Compenwtion provisions oi the Lobor Code,yo�must forth- Oven _�ryer _W.M._ ADDRE55 �jx 1111
with comply with such prov�sions or fhis permi1 sfial{ be Top —FAU --W.H.—
( deemed revoked. C�N CI'l�110 91708 Te�.�o. 591-b461
� LICENSED CONTRACTORS DECLARATION Hood _Fvn _O�her_
LKENSE OR
�isp. _Room Air Cond. ____ R[G.NUl�teeR 490053 ��OS$� C"1�
t hereby affirm that I am licensed under provisions of Chapter 9 a
(commencing with Section 7000)of Division 3 of fhe Business pow�qP�ratus 8 large Appliances DISTRICT NO. PROCESSED BY D�
� and Rofessions Code,and my license is in f�ll fwce ond effect. I�– �
[[[ Size&Type HP,KW,KVA,or KVAR L
{ License Numbe� 1+A�1(1R3 Lic.Class C.�70' FINAL � �
' Up to 1 Incl. Q
� Electrical 8/29J86 o�e�1 to IO lnd. Di4� /Z-�J= VAIJDATION �'
� Conirotlor Date Over 10 to 50 Incl. F�NA� a
❑ I am exemp�under Sec Dver 50 to 100 Inc. B� �
� 8.8P.C.for this reason Over 100 � Z
� ��e. Sarvices,Swbd.,MCC 8 Ponelboa,ds �
0-Z00 Amp.Under 600 V
� Signature 20l-IOOD Amp.Under S00 V ,_� ��,L1 A
� � Ovar 1000 Amp,or Over 60p V
` Exemptlon for Reg.Mainl.Elect. f�• • • • •2
`� SINGIE FAM�LY Temp.Power Pole 8 Appurtenances
� HOME OWNER-BUIL�ER DECLARATION Sign wirh One 8ranch Ci�cui� f �•�3�O�
� I hereby affirm thai I am exempt from the Contractor's License Add�tional$ign 8ranch Circuih • • •i;7(�2�
! Law for the followinq reoson (Section 7031.5,Business and
� Professions Code):
; � Misc Conduiis 8 Conducton ���'.C�S"'$6
I,os owner of the p�operty,will do the work and�he
I srrudure is not intended or offered for sale(Section O�her(See Complete Pee Schedule)� ►
� �044,Business ond Professions Code).
� CONSTRUCTION LENDING AGENCY
� I hereby affirm that ihere is a�onstr�ction lending agency for
�he performance af the work for which this permit is issued PERMIT FEE (Sub-Total) 62 2
(Sec.3097,Civ.C.).
PLAtd CHECKING PEE
Lender's Name
PERMIT ISSUING FEE lO. O
Lender's Address ]3.�•z
I cer�ify that I have read this application and slafe thaf Ihe TOTAL FEE
above infamation is crnrecL I agree to comply wifh all Coonty
ordinances and Stale�aws reguloting Electrical wiring,and
hereby outhorize representatives of ihis County to enter upon
Ihe v ve-meMion propeny for inepetlion purposes.
SEE REVER5E FOR EXPLANATORY I.ANGUAGE
�,d 8/20/86
S�gnature of Permitiee �ate
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