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WORKERS'COMPENSATION OECLARATION C� FO/Bt APPLtCATlON FOR E.LECTRI�A! PERMIT
I here6y affum that i have q certificate aE consent to self . . . �
- insure,or p cert"rficote of Workers'Compensa�ion Insoraote, C�UMTY OF LOS ANGELES � BUILDING AND SAFETY
or o cerNf e co �t reof{Sec 3800,lab.C.) � . -
Po''cy ompan� � fOR APPL4CANT 70 FI1l IN -.�..... . -JOB . . ...
. p . e r �y�s erehy f�tn�shed. - - : � � EAGH Np. FEF A�R�gDl
� -- � -�- -- . New-Rgsidential8ldgs.¢�4qo{ .
" �erfiiied copy rs fited with the county bvilding-inspeo- i&2-Family,Sq.Ft.� �f F — 5 IOCALITY � • .
... ��tion departmeqr _.� .. ... . AAulti-famJy Sq.Pf. ��-- --._ _ ..- ..- _— ._ . __ NEARESF �! . .
Date^�T��Applican� 5+��/'lL�� � Residenhal Swimming Pools oCR055�5T.� L-O'�" 70
� - fIRM NAME ���
CERTtflCAT"E OF EXEMRTlON FROM WORKfRS' Outlets:Rec_LigM_Sw._ --- � � ��
C4ktPENSATION tNSURANCE Fint 20 A��
(Thfs saelWn nHd nat be compleTed i!tho wark.iarclved 6y Tarol FJo. - � � C4TY • Tet.No. 4�
thr pormit I�for oao hundrod doiMrs(5100}or tys.} A�ictitionni _ _
I tertify that in�thc perfwmance o{the work-for which this � PtAN CHECK_.__, �
ermit is issued,!shaft not e In an - - APPLICAM �
p mp y y person in any man�er Li htin Fixtures First 20- �
sa w to become sa6�ect to-the Workers CompensaTidn taws. 9 9 ADDRESS
� � Tofaf No. Add'�tional �-� -
. .. CiTY Tel.No.
�°�� �PPC1CO6� Pixed Appliances Not Over 7 HP
NQTIC€70�APPIICANT: If, ofter making�tfiis Ceriifimte of ��tt � � n n '
- Exemption, you shouW become subject to the Workers' Range_Heoter_D.W._ �Pt�CANT _`,�' .-� F7.FY`1'RTC .
._._.-----�.._ .
� Compensation provisions ot�ihe tabor�Code;yau musl forth- Oven _Dryer _W.M._ � ADDRE55 �--�- � � -
- wifh comply with such provisions w fhis permit shalf be Top _fAU _W.H.— -
deemed revoked. Hood _Fan _Other_ c�T�` Tef.Ple
� - � -UCENSED CONTRRCTORS DEGIARAFION.- LICENSE OR•
�"- f�hereby�affirm tkwtt am 4Feensed uruier pr6visions�ofCfiapter9 Disp, _Room Air Cond. — REG.NUMeER -Cluss.
. {commerccing�with Sedion�-7WQ�af Oi-vision 3 af�the Business power Apparo�us S la�ge Jippliances � Q���T�O•. �f` . Blt �
. arrc�Rcrfeuions C�e,vnd mylicense is:in tutl�force and�eifect.- . . v 6
�t �J� Size&Typa HP,KW,KYA,or KYAR' �
- Cfcense Number���Lic.Clau� - � � .
Up to 1 IncL PFNAL --- V
- �����IAC.� )����` Over}ro 10 tnd - DATE �� t . .�i p�
YAtbJ1TIQN
. �Contractor Qote.y!?_:3'�_e�" Over 10 to 50 Ind. - { •) � Q
_ ❑ !am exem t under Sec. � &Y A , . �
P Over 56 to IflQ Inc.
- . 6.8P.C.for this reason Over 100 � 4'
H
.. . � Date:.. Services,Swbd.,MCC&Panefbourds � . � ..-.. �
. - . U-406 qmp.Under 600 V � - - -
. Sigrwt�re 20t-1000 Amp.Under 6Q0 V . .- .... -. . � - 'a 9�7 f1 6{}
� -❑ . . Over 1[�p0 AmP.�6ver 60U V .
Exemption fw Rag.Maint.Elett. ��'� � � �G
- 51NGlE FAMRY � - Temp.Power Pole 8 Appurienances � ���a, Q �
HOME OWNER•BUfLDER DECLARATION Sign with One Branch Circvit
I hereby aHirm that f am exempt from the Contradar's license .
_ Law far}he foIlowing reosort(Section 703l.5,Business aod Additionai Sign Brvnch Circu'�ts - - - � �.• • �f��,1.��
Professions Code): � . � . �7`G�—�5 .
❑ I,ns owner of the property,will do the wark and the Misc.Conduits&Condutlor: � � .
. � strudure is not imended or offered for sa#e (Section 01her(See Cpmpfe�e Fee Schedule}_ � .
7044,Business and Professions Code}. � �
- CONSTRUCTION LENDING AGENCY � - � �
I hereby offrrm that there is a construction 4e�ding agency for � � � -
fhe performance of the work for whith ihis parmit is issued PERMIT FEE (Sub-Total) �
(Sec.3Q47,Civ.C.j. . . ..
- - � - PIAN CHECKtNG FEE � - -
� Lender's Name - - � � -
- � PERMIT�ISSUING FEE ..
Letider's Address . -
. I certify thoi f have reod this opplicotion and state that the TOTAL FEE. . .
, nbove infwmation is cwrect I agree ro comply with all County -
ordinQnces and State laws regoloting Elettricol wiring,and - � -
- hereby authorize represeMatives ot ihis County to enter�pon - . �� .
the above-men�ioned property for inspection purposes. SEE REYERSE FOR EICPLANATORY LANGUAGE
�C�C� �C ' - S
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