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WORKERS'COMPENSATION DECLARATION �6� �o,e, APPttCAT10N FOR ELECTRICAL PERMIT �
I hereby affirm Ihot I have a certificate of consent to self �E'�
insure,or a certificate of Workers'Compensation Insurance, COUNTY�F LOS ANGElES BUItDING AND SAFETY
or a certified copy thereof(Sec.3800,lab.C.)
P�ol�icy No. Company FOR AVPIICANT TO Fltl fN qppRESS � p� �
Certitied copy is heraby f�rnished. Naw Residenlial 81dgs.8 Pools EACH NO. FEE
� 1 8 2-Famil lOCALITY
Certified copy is filed wiih the caunty bui�ding inspec- Y,Sq.Ft. E — S .(��,,
t�on departmenf. Multi-fomi�y Sq.Ff. — NEAREST ��U
CRO55 ST.
Residential Swimming Poofs
Dote Applicant OWNER OR \
fIRM NAME
CERTIFlCATE OF EXEMPT�ON FROM WORKERS' Oudets:Rec Light_$w,� ���
COMPENSATION INSURANCE ADDRESS
Thla sactioa aeed�t be Firot 20 0�
( wwptaod if tha work levolvsd b� 7ota1 No. Additlonal CITY Tel.No.
Iha pormif is ior ww hvndrod dolkn(�tYO)or iets:) -
PWN CHKK
I certify that in Ihe performonce of ihe work for whicb this APPLICAM
permit is issued,1 shall not employ any parson in any manner
so as to become subject to lhe Workers'Compensation Laws. Ligh�ing Fiztures First ZO ADDRE55
Tolal No. Additional
CITY Tel.No.
Date opplimnt Fixed Appliantes Not Over i HP
NOTICE TO APPLICANT: If, afrer making ihis Certifkate of APPItCANF ��.�1/�l�
Exemption, you shovld become s�bject to the Workers' Ra�ge_Henter_O.W._ I
Campensation provisions of thc tabor Code,you musf forih- Oven _Dryer —W.M._ ADDRESS
with comply with suck provisions or this permif shalt be Top _FAU _W.H.—
deemed revoked. Hood _fan _Other_ CITY Tel.No.
LICENSED CONTRACTORS DECLARATION uc�vse Oti �
1 here6 aHirm tFwi{am licensed under Disp. _Room Air Cond. —
y provisions oF Chvpter 9 REG.NUMBER Closs �
(commencing wi�h Section 7000)of Division 3 of the Business power Apparatus 8 Large Applionces DISTR{CF NO. PROCESSE Y
and P.ofessions Code,and my license is in full force and effect- j " } �
Size 8 Type HP,KW,KVA,or KVAR (� ��� �
License Number Lic.qass Up to 1 Ind_ FINAL U (
Over 1 to 10 Ind. DATE p� �
Controctor Dete VAtIDAT1pN 0
Over l0 to 50 Ind. ��Nq� V
❑ I am exempt�nder Sec. Over 50 to 100 Inc. BY �y
B.&P.C.for Ihis reason Over 700 y
Date: Services,Swbd.,MCC 8 Ponelboards � g
0-200 Amp.Under 600 V
Signature 20T-1000 Amp.Under 600 V
❑ Over lODO Amp.or Over 60p V �
Exemption for Reg.MoiM.Elecl.
SINGLE FAMILY Femp.Power Pole 8 Appurtenances �, 1 �$A 1�
HOME OWNER-BUILDER�ECLARATION Sign with One 8ranch Circuit
I here6y affirm ihat I am exempt from fhe Coniractor's�icense �
law for�he following reason(SeUion 7031.5, Business and Additionol Sign 8ianch Circuih #• • • • �L �
Professions Code):
� I,as owner of the property,will da the work and ihe Mizc.Conduits 8 Conducto�s � • • '� �j,�j(� '
structure is not inlended or offered for sale (Sedion Olher(See Complete Fee Schedule)_ � _ �
7044,Business and Professions Code). •� • 1 a 5 0 c .
CONSTRUCTION LENDING AGENCY 0 1.c 3-8 4 �
1 hereby offirm that there is a construction lending agenty for i
the performance of the work for which�his permit is issued PERMIT FEE (Sub-Total) �
(Sec 3097,Civ.C.�.
PLAN CHECKING FEE l • �
Lender's Name
PERMIT ISSUING FEE
Lender's Addrass
I certify thal I have read this application and s�ate that�he TOTAL FEE
above information is correct.I agree to comply with all Co�nty
ordinonces and State laws reguloting Eleclrical wiring,and �
hereby aufhorize represenlotives of ihis Counly to en�er upon
e above- Gptioned property far inspection porposes. .
�� v. ` ��� SEE REVERSE FOR EXPIANATORY LANGUAGE
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