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WORKERS'COMPENSATIONDECLARATION ��'� ���81 APPLICATION FOR ELECTRICAL PERMIT ,ti.o;�
I hereby affirm�hot I have a certificaie of tonsent to self CE-806G . ��
insure,or a cer�ificate oi Workers'Compensation Insurance, COUNTY OF LOS ANGELES - BUILDING AND SAFETY
or a certified ca y thereof Lob.C.,L 3
Paolicy No����� Co ny� - FOR APMICANi TO Flll IN JOB � /
Cerlified copy is hereby furnished. New Residenliol Bldgs.8 Pools EACH NO. . FEE aDDRE55 1,.�•
� 1 8 2-Famtl Ft. �S� f — E O G� ��ALITY
Certilied topy is filed wi�h the counry building inspeo Y•S9� �
� tion daportmenL - � � Mulli-family$q.R. — NEAREST -
(� C�, Residentiol Swimming Pools OWNER OR
pote — V'�L Applicam��•^A�_ .
FIRM NAME
CERTIfICATE Of EXEMPTION FROM WORKERS' � Outlets:Rec_Light_Sw._ '�'p'��
GOMPENSATION INSURANCE � ADDRESS
Thi�i�clten nwd noT be com I�f.d if fh�work involwd b -Firsi ZO
( ° P � Total No. Additional CITY TeL No. _ '
the permif h(or one hundrod dollan(SI00)or lets.)
I certiiy Ihal in Ihe perfo�mance af Ihe wark for which this q�pp�N(-,�qryTK
— permit is issued,I shall not employ any person in any manner � --
so as to become subjecl�o�he Workeri Compensotion laws. Li9hting Fixturas Firs�NI ADDRESS �
. - � Total No. Additional CITY Tel.No.
Date opplicant � fiKed Applionces Not Over 1 HP PERMiT
„�TICE TO APPLICANT: If, afler making this Certificale of ApPlIG4N
mption, you should become subject to the Workers' . Range_Hea�ar_D.W._ .
.•.ompensation provisions oi�he Lobor Coda,you must forth• Oven _�ryer _W.M.— � ADDRE55 d
with comply with such provisions or �his parmit sholl 6e Top _FAU —W.H.— � �
deemed revoked. . � � CIN - Tel.No.7,�?
Hood _Fan _Orher_ .
IICENSED CONTRACTORS DECIARATiON � Dis _Room Air Cond. — LKENSE OR Class��
I hereby offirm that I am licensed under provisions of Chopter 9 P' REG.NUnneER
(commencing with SeUion 7000)of Division 3 oF�he Business DISTRICT NO. PROCESSED BY
Power Apparatus 8 large Applianres >'
ond Professions Code,and my license Is in full force and effed. . /O � ' p,
Size&Type HP,KW,KVA,or KVAR- �� O
License Number 4�a� Lic,Clos` - ' FINAI ��� � � V
Up to 1 Incl.
Over 1 to 10 Intl. DATE � � 1 a`(, VALIDATION Q
Contracior � �� Da�e Over 10 to 50 IncL FINAL ' T' V
❑ I om exempt under Set. � Over 50�o IOO lnc. . BY �`��r�� . __ �+
Over 100 �
8.8P.C.for this reason y �
� Servicas,Swbd.,MCC 8 Paneiboards � � Z
Da�e: 0-200 Amp.Under 600 V -
Signature 401�-1000 Amp,Under 600 V - �
❑ Over 1000 Amp.Or Over 600 V
Exemption for Reg.MoiN.Elect �
SINGIE FAMILY . Temp.Power Pole 8 Appurtenances.. .
HOME OWNER-BUILDER DECLARATION Si9n with One Branch Cirtuit � ��O�T.'J A
leby af(irm that I am n.empt fmm the CoMmttor's license Additionol Sign Branch Circuits � - - � � � � � �
.�(or fhe following reason�Section 7031.5,B�siness ond � 2
Proiessions Code): - . � �
❑ I,os owner of the property,will do tha work and ihe Misc.Conduits 8 Conduclors - " �,•,•7 Q Jr� �
structure is not intended or oHered for sale (Section O�her(See Complete Fee Schedule)_ ► - .. •_• �7 Q 5 O=
7044,Business and Professions Code�. � " -
� CONSTRUCTION LENDING AGENCY . � ���� 8�H 4
I hereby aHirm that there is a construction lending agenty for
the performance oi the work for which this permil is issued PERMIT FEE � � (Sub•To�ol) � � - - -- -
(Sec.3097.Civ.C.). � . . .
� - • PLAN CHECKING FEE - � � � - � - � --
tender's Name -
PERMIT ISSUING FEE . . � .
Lender's Address � � ' . -
I cerlify thot I hove read thi5 applicotion ond state Ihot Ihe TOTAL FEE .
o6ove informalion is torreU.I agree fo comply with all County , .
ordinances ond Sto�e laws regulating Eleclrical wiring,ond . _ , _
hereby authorize represeniatives of�his County to enler upon � � �
the o6ove-meniioned praperty for�nspect�on purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�pA -�
$ignature oi PermiHee Date
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