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WORKERS'COMPENSATION DECLARATION 76A663 �o,e, APPLICATION FOR ELECTRICAL PERMIT � �
I hereby affirm 1ho1 I hove a cerlifitote of consent to self �'8�
insure,or a cenificate oi Workers'Compensaiion Insurante, COUNTY OF LOS ANGELES � BUILDING AND SAFETY
� or a certified copy ihereoi(Sec.3800,lob.C.) . � •
POol�ity Na. Company FOR APPIICANT TO Fltl IN - �� �
Certified copy is hereby furnished. New Residenlial Bldgs.8 Pools EACH NO. fEE ADDRESS
� Certified copy is filed with Ihe co�nly building inspec- 1 8 2-Family,Sq.Ft. S — S ���LITY
tion department. � � Multi-family Sq.Ft. CROSSSST. lA.�
Dale Applicant � � Residenliol Swim Pools FlRM NAME �
CERIIFICATE OF EXEMPTION FROM WORKERS' � Outleis:Rec_Liqh�Sw�._ �O N`°'il .
COMPENSATION WSURANCE - - •� aooRESS �
F��S,so �; �
(Thl�f�eHon n��d not b�complN�d if th�work Involvad by Total No. Addi�ional CITY - Tel.No.
1hs permit is for one hundrad dollars(SI00)ar lass.) .
I certify Ihal in Ihe perfo�monca of tha work for which thit �N CHECK
APPLICAM
— permil is issued,1 shall not employ any persan in any manner � __
so as to become subject to�he e C mpensatb Lai s. ��gh�ing Fizmres First 20 A�DRE55
To�al No. ' Add�tional
�Date Applicanr � CITY Tel.No.
NOTI E TO APPLICANT: If, afler making lhis Certi(icate of FiKed Appliances Nof Over 1 HP pppM��,rpNT
Exempt�on, you should become subject io �he Workers' Range_Heoter_D.W._
Compensotion pravisions of ihe Labor Code,you musl forth- Oven _Dryer —W.M.— ADDRESS
wi�h comply w'th such provisions or �his permi� sholl be Top _FAU —W.H.—
deemed revoked. � � � Hood _Fan _Other_ CITY - Tel.No. � -
LICENSED CONTRACTORS DECIARATION tICENSE OR
�hereby aHirm tha�I am litensed onder provisions of Chapier 9 Disp. _Room Air Co�d. — REG.NUMBER - � Closs.
(commencing with Section 7000)of Divislon 3 of the Business power Apparatus 8 Large Appliances DISTRICT N i� PROCES D BM1 ^ �
and Profess�ons Code,ond my litense is in full force and eHect. ,
Size 8 Type HP,KW,KVA,or KVAR ""�•- 0
License Number. lit.Ciass - - - - Up to I Intl. F�Np'� � V
� O�er 1 to 10 Ind. DATE VALIDATION �
Contracror Dale Over 10�0 50 Ind. � �"
O FINAL �J .
I om exempl under Set. �Over SO to 100 Inc. BY �+
G.
Over 100 � ,
B.BP.C.for Ihis reason . - 2 .
Dme: Services,Swbd.;MCC 8 Panelboards �' � �� —
0-200 Amp.Under 600 V
Signatu�e 201•1000 Amp.Under 600 V � � -
❑ Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
$INGLE FAMIIY Temp.Pawer Pole 8 Appurlenonces . �O��6�.
HOME OWNER-BUIIDER DECLARATION Sign with One 8ronch Circuit� �
1 hereby oifirm Ihot I am eaemp7 from Ihe Controcfo�'s litense p,�,�;�����1 S�pn Rmnrh C��ru�ts � R , �• • ° • •G �
Low for the fol�owing reason(Section 7031.5,8usiness and ���
��Prof/es�Yons Code): � . . �." •3 0 5 0
LJ I,as owner of ihe properfy,will do 1he work ond ihe Mrsc.Condoits 8 Conductors =
shucture is no1 in�ended or otfered for sole(Section O�he�(See Complete Fee Schedule)_ ► n\ + ^ �J Q.S.��
70d4,Business ond Professions Code�. �'� -
� CONSTRUCTION LENDING AGENCY - ��n O G Z� "S S
� �r
I hereby alfirm�hat ihere is a construction lending agency ior
ihe performonce of 1he work for which this permit is issued PERMIT FEE� - - -�� -- �- � ISub-Torol) - - . .- . .. .
(Sec.3097,C�v.C.). �
PIAN CHECKING FEE � - - . (�� - �
lender's Nome - �V ` '
� PERMIT ISSUING FEE . � , .
Lender's Address �
I certify ihat I have read rhis application and vate that the - TOTAL fEE '�jO . . . � .
above informotion is torrecL I agree to comply wilh all CooNy � .
ordinances ond Slale laws reguloting Electrical wiring,ond . ,
. hereby authorize represeNatives oF this County to enrer upon
th bove-m nt�oned property for inspection p�rposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
�c� � a!-�
Signatwe of Per itlea �ate
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