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WORKERS'COAIPENSATIONDECLARATION CE�e s��z.so, AF�PLICATION FOR ELECTRICAL PERMIT .. �
I hereby aifirm that 1 have a certiticate of consen� to self COUNTY OF LOS ANGELES BUILDIN('i AND SAFETY �
incure,or a certificate of Workers'Compensation InSuronce,or
a certitied copy tfiereof(Sec.3800,Lab.CJ� � ' � '
FO R APPLICANT TO FILL IN n/./��HS�
� Pollcy No. Compaqy EACH� NO. FEE ADDFiESS � � i'—_ � ',
New Residentisl Bldgs.&Pools
❑ Certified mpy is heroby furnished. 1&2-Family,Sq.Ft. $ '— s LOCALITY
�1 .h Gf !.3
❑ Certified co y b filed with the count buildin Ins eetion Multidamily Sq,Ft. � — NEAREST
v r e p cRoss sr �pwk� G t�'�'�' td� _
Jepartment. Res' ential Swimming Pools � � OWNER OF ^ ,
-2� FIRM NAME /�
Datr � - Appticant � Outi [s:Rec._Light�_Sw._ MAII
First20 ADORESS " �Nf/�} L
C£RTIFICATE OP EXEM1IPTION FROM WORK[iR5' Total no. Add'+tional
� COhiPENS�TION INSURANCG � - CITV � �-►trel No. '2 ��tZ
}
. ' PLAN CHECK d
— This section need not be completed if Iho wo�k inYOlVOd � A.PP�ICANT O
y the permit is for one hundred dopazs (5100) or Iess.) � �-ightinq Fixtures First TO- ADDRESS . �� � --
Total No. Additional
certify that in the periormance nf the work for which this j Fixed Appliances Not Over 1 HP CITV Tel No. 0
rmit is issurd,7 shall not emptoy any person in any msnner � PEiiM1T U
as tn hecome suhject to the Workers'Co sation La�vs. i RdnyO__�H88[Bf_D.W,_ APPLICANT cJ W
a
Oven �Dryer_W.M._ aooREsS y
Top _FAU _W.H,._ z
tel2 3 JS�PPlicant ^ . .
� Hood_Fan _Other_ CITY Tel No.
TICF.TO AI'PLICANT:If,after making this Certificate of Disp. _Room Air Cond._ LICENSE OR
mption, you should berome subject to the Workers' � REG.NUMBER Claas �
pensation provisions of Iht Lshor Code,you must forth- ! Power Apparatus&L2rge Appliances �ISTRICT NO. PfiOCE�v �
p wmply with such provisions or this permit shail be Size&T HP,KW,KVA,or KVAR
lmed revoked. � VPe
r ' �P to,����. i o .�
! FINAL
J 'Over i to 701nc1. �ATE 1���/� VALIDATION
LICENSED CONTRACTORS DECLARATION .
f Over 10 to 50 Incl.
� 1.hereby aflirm Ihat I am Iicensed under provisions oT Chapter Over 50 to 100 Inc. FInIAL � �
BV
9 (commencing with Sectlon 70DD)ot Division 3 of the Rusi• Over 7Q4 ...�,�^2 _ O� � �
ness and Protessions Code,and my license is in fWl force and � — v�•� �C��h�� �
etfecl. � " . " .! $¢rvices �
� � 0-200 Amp.Vnder 600 V
License Number Lic.Closs 201-1000 Amp.Under 600 V - -
Contractnr � nate Over 1000 Amp,or Wer 600 V � '
HOMG 01VNER•BUILDER DECLARATION . Temp,Power Pole&Appurtenances � � � �
I Sign with One Branch Circuit 0 S 9.b A
f hereby affirm�that f am exempt from the Coniractor's � A���tional Si;n 9ra.^.ch Circuits ' � '�
I,icense Law for the following reason (Section 7031.5,Husi• . .
ness and Professions Code): � - , tt+ • ••►,�2'
� Misc.Conduits&Conductors
� 1,as owner ot the property,will do the work and Ihe -� Other{$ee Complete Fee Stheduie)--- ' � • '2�5�
structure i: not imended or otfered for sale (Section � -
1044,Business and Professlons Code). �� � �2�5�,� � .
CONSTRUCTION LENDING AVENCY . u
1 hereAy aftirm tha[ [here is a construction lending agency � �G�3�a�,�
_ for the performance of Ihr work for which this permit is " pERMIT FEE (Sub-Tataq �� �
issued(Sec.3097,Civ.C.). � . �
Lender's Name � PLAN CHECKING FEE (One-Fourth Permit Feel ,
LenJer's Address � PERMIT ISSWNG FEE �j . �
1 certify�ihat 1 have read Ihie spplicaNan and state ihat the TOTAL FEE � ^ � �
.�C
' above information is eorrect I agree lo compiy with all County �
nrdinances and State la��s regulating Electrical wiring, and "
hereby thorize reprrs tatives of lhis County to enlcr upon �
the/al ve ientioned o rty for inspection purpases. � SG6'RGVERSE FOR L•XPLANATORY LANGUAGE�
!` YL � 'zr.7-dl � � � . . .
Signature of Permittee Date
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