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WORKERS'COMPENSATION DECLARATION �bA�3 �o,e, - APPLICATION FOR ELECTRICAL PERMIT �
I hereby affirm thot I have o certi{imte of tonsent b seff CE�906G �
insore,or a cernficare of Workers'Compensation Insorance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a tertified copy thereof(Sec.3800,Lab.C.) � � � .
P❑olicy Na � Company FOR APPLIGM TO FILL IN � � �Oa -�tL/
Ce�liiied copy is hereby f�rnished. New Res(dential Bidgs.8 Pools EACM NO. FEE AODRE55 � /
� 1 8 2-Fomil FI. f — E �°�'4��TM �,g-
Certified copy is filed wifh the county building inspeC- Y'�' NEAREST
tion deportmem.� _ � Molti-family Sq.FI.� GROSS ST. ry �,
Do�e Applitont ' ResidenlialSwim g ools , OWNEROR �
�\�0. - FIRM NAME / .
� CERTIFICATE OF EXEMPiION FROM WORKERS' � putlets:Rec_Light_Sw.__ � �'��
COMPENSATION INSURANCE � � A�� - Q� N -
fThlf seet�on nnd not b�Eem IN�d�f th�work Inrolv�d b � Firsi 20 '
hs parmlf i�For ono hundred dollen(5100)or loss.)- �Y To+al No. ..Addilional CITY �� �y�-� Tel.No7�y
I certify that in the periormance of the work(or�which this� � - - APAVLNICANTK � �
permit is issoed,I shall nol employ ony person in ony monner � � -
- so os to'become subjed to the Worker GompensatioBQows. lighiing Fiztures , � First 20 ADDRESS
� Addirionol
/ � ��..��� Total Na � � CITY � - Te� No.
y�Doie���---f�'"PPlicant Pixed Applionces Nol Over 1 HP PERMIT
1 NOTICE TO APPLICANT: If, afler moking Ih' ertificote qpp����T
Exemption, you should become subject the Workars' Ronge_Heater_D.W.— ,
Compensafion provisions of the Labor Code,you most{orth- Oven —Dryer —W.M.— � � ADDRESS � �— �
wilh comply with such provisions or Ihis permil sholl be Top _FAU� —W.H,— �
� deemed revoked. � �� � � CI �.r,�y, /�.i . �o.���SI -
Hood _Fon _Othe�—
� LICENSED CONTRACiORS DECLARATION : � LiCENSE OR � �
1 hereby affirm fhat I om licenzed under provisions of Chopler 9 Disp. _Room Ai�Cond, — pECa-NUMBER � - C�a�•
(tommencing with Seciian 700D)of Division 9 of ihe Businass DISTRICT NO. P ESStB�aY
and Professions Code,and m license is in full force and effect. Power Appamtus 8 La�ge Appliances . . � Y
Y . Size 8 Type NP,KW,KVA,or KVAR� � \O \ " � Q �
litense Nomber Uc.Class � �� -� -Up to 1 Ind.� ' FINAL- - V
- � � � Over 7 fo 10 Ind. DATE yAIIDATION �
Confractor � �ate Over 10 fo 50 Incl. FINAL .. O �..
❑ _ V .
I am exempt under Sec. - Over 50 to 100 Inc.-. 8Y �++
d
8.8P.C.fo�this reoson Over 700 - Z
. . Servites;Sw6d.,MCC 8 Panelboards � - � -� � '�
� . . . 'Date: �� 0-200 AmP.Under 600 V . . �`t/� � .
S�gnolu�e � ZOl-1000 Amp.Under 600 V " � -
❑ � � � Over 1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elett. �� I' /f
SINGLE FAMILY Temp.Power.Pole 8 Appurtenances. I�!J _ ._. ._
HOME OWNER-BUItpER DECLARATION � d
I hereby affirm thar I am ezempt from the CoMrador's License Sign with One Bronch Circuit . / �� 4 2 4.A •
Law for e(o l lowing reason(Sedion 7 0 3 1.5,Bosiness on d � Additional Sign Bronch Cirt�its .
. Prof ions Codej: . , .�� . . #• • • •�'•Q
�\ I,as owner o(the property,will do the work and the Misc.Conduits B�Conduc�ors� � � � � -- :
. slr�crure is not inlended or offered for sale(Section Other(See Comple�e fee Schedule)_ �,• •3 Q 5 0
�7044,Business and Professions Code). ► • s �3�p,5 0�
CONSTRUCTION LENDING AGENCY ' . � �O 2 O 7-H�l
I here6y afiirm that there is a construtlion lending a9ency for � - �
the performance of the work for which this permit is issued PERMIT FEE � � (Sub•Total) - � � - - - � � ��
(Sec�3097,Civ.C.J. . � , � � .
� . - PIAN CHECKING FEE � � �. . . .. . _
Lender's Name �O .
� PERMIT ISSUING FEE � .
lender's Address � �
� I certify�hat I have read this applimlion and state thot the TOTAL FEE • � � �
obove information is corrett.I og�ee lo tomply wirh all County
ordinances and Sicte laws regulofing Elettriml'wiring,and � . _ _ .
- here6y authorize representalives of fhis CouMy to enler upon , � � � -" ��� - �
he a �-memioned proper� far tnspeteon purposes. _. SEE REVERSE FOR EXPLANATORY IANGUAGE
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