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WOFiKERS'COMPENSATION DECLARATION 76ne63 tv87 ;
� CE-806G QPPLICATION FOR ELE�.�T��C. L PERMIT , . �
I here6y affirm that I have a certiticate of consent to seif insure, t � � - : � .,`'h � e:H:• i
or a certificate ot Workers Compensation Insurance,o�fied COUNTY OF LOS ANGELES � � f��1�C'i A� .�S/;}FETY i � °5� "� �
copy thereoi(Sec.3800,La4,C.) � � '
a�o�xY k . �. ;
Policy No. Company� FWt APPLICANi TO FILL 1N � �
❑ CertiFied c�e6y furnished. New Residential 61dgs.&Pools EACH NO. FEE ��E55 2!o Z3 J�` n ✓✓1 ;
1&2-Family,SQ.Ft. � — $ L O C A L I T Y q�
�Ceitified�copy is filed with the co y huilding inspect� _
deoartment. Multi-0amily Sq.Ft. NEAREST /
Cf105557'-- Lr
Date�_Applica Resitlential Swimming Pools _ p�y�p pp
FIRM NAME p✓)
CERTIFIGATE OF EXE I FFOM WORKERS' � L � � � � � ��L
COMPENSAT NSURANCE Outlets:Rec—Lighi Sw.—
nooriEss
(This section need noi 6e completeQ'rf the wak involved by the First 20
permit is for one hundred tlollars($100)or less.� Total No. Additiorel Cf7Y Tel.No.
PLAN CHECK
t certify that in the perfarmance of tha worfc for which this permit APP�iCANT O
is issued,f shall rrot employ any person in any manner so as to
6ecome su6jec}to the.Workers�Compensat-n Laws. Lghting Fixtures First 20 � I ADDRESS .rj„Jyv
Additional
Total No. CITY Q � Tel.No.
Date � MP���a Fixed Appliances Not Over 1 HP
NOTIGE TO APPUCANT�, If_3f ._ flwking,this C ifirate of PEFMI ��
Exemption,you should b2co � iect to the Workers'Cort�ensation Range—Heater_ D.W. _ aPtticnrvT �'
provisions of the Labor Co ' u must forthwith comply with such Oven_ Dryer� W M._ AOORESS �
provisions or this aerrNt sha I 6e deemed rewked. Top _ FAU _ W.H._
LICENSED CONTRACTORS DECLARATION Hood— Fan _ Other_ GCFY Tel.No.
I h e 2 b y a f f i r m t h a l I s m l i c e n s e d un d er pmvisions of Ch2 pter 8 LICENSE oit
(commencmg with Section 70001 of Division 3 of fhe B�iness and Disp. — Room Air Con d. — REG NU�BEa � � c i a ss. f
Professions Code,and my license is in tult force urui effect. �ISTRIC7 N�. PROGE55� � �
Power Apparatus 8 Large Appliances
�'/f y Size 8 Type HP,KW,KVA,or KVAF m �/�c R �
LJcense Number J"d��P Lia Class �_Llp to 7 Incl. w � V FlNAL �+
S ��' _ ��sL� �". Over 1 to 101ncL �ATE VpLIDATION Q �
Conhactor Oate Over 7�to 50 Incl. !
❑ FINAL �j i
I am exempt under Sea Over 50 to 700 Inc. BY �
Over t0o �
8.&P.C.for this re:aaor tn
Services,Swbd.,MCC&Panelboards � ^ �
Date: 0-200 Amp.Ur�er 600 V _
Signature 201-70D0 Amp.Under 600 V �
❑ Over 1000 Amp.or Over 600 V 1 �
Exempti f eg.Maint EIecL �{ ��� � J
SINGLE FAMILY Temp.Poiuer Pde 8 Appurtenances #� ����2 �
HOME OWNER-BUIIDER DECLARATION Sign wilh One&anch Circuit
I heretry aflirm that I am exempt from the Contractors License Law '� •t 2�,Q Q
for the followin reason Section 7037.5,Business and Professions +��tpnal Sgn Branch Circuits
y i ••i2�0Q� �
Code):
❑ -- Misc.Conduits 8 Conductors fl Q.�3-`'8 4 �1
I,as owner of the property.will do the work and the structure �
is no�interxied or offared for sale(Section 7044,6usiness Other(See Comple�Pee Schedule)_ �
and Professions Code).
CONSTRUGTION LENDING AGENCY �
I hereby alfiim that there is a construction lending agency for the
parformance of the wak lor which this permit is issued(Sec.3097, pERMIT FEE (Sub-Totaq
Civ.C.1.
� PLAN CHECKING FEE
Lender's Name
pERMIT ISSUING FEE
Lender's Address
I certify that i have read this application and state that the ahove TOTAL FEE �
information is correct.I agree to comply with all County ordinances �
and State laws regula4ng ElectriCal wiring, and hereby authorize
representaCves of this Gounty to enter upon the above-mentioned
property r inspect�on purpa�s. SEE REVERSE FOR EXPLANATORY LANGUAGE
� �z�� �
gnature of Permitt e Date
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