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l':O4KERS'CO'SFENSATION DECLl�RATION �tA�� �o�e� APPLICATION FOR ELECTRICAL PERMIT ' `,F'� �
1 hr.reby ofLrm ihnt I hnvr. o tcrlifica�r. oI mnsent m self �F"n�'
insure,or o r=riiFicnie of`lJor4ers'Compnnso��on Insi�mnce, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a cei�i(ied copy thnreof�nSeb?600,L}n-b.C.) �
Poli�y No���•npony�/� � O � FOi AYYLIUNT i0 FILL IN JOB
� Cerli(ied cepy is hereby furnished. Nr.w Resid�n�iol 61dqs.8 Pools Fa.CM 1.'O. �FE ACDPESS IV (L�O��
� S — 5 LO:ALITY J
Cenified copy is filed wirh ihe couniy buildin�inspec- 1 8 2-Family,Sq.FL I A
—� NEAPlST /' �
tion�lrperimcnt. ['� 1.Aulii�fomily 5�.FI. C�O55 ST. (�- I �
S/g�r, �P y�( /�'�y� Residenliol Swimminq Pools O'f11.ER OR
Dafc_( A Iic�nl�L�r`-"� � fIA•.1NAME E �R
CERTIFICATE OF ExEMPT10N FROM WORKERS' Ou�le�s:Rec_L�ght_Sw._ � ' ` ' �'�'��� n ��f
COVPENSATION INSURANCE ACDRESS J ' l. f�/ D� /
Thi�s�clion n�ad not bs com I�tod if the work fnvolved 6 First 20
� p Y Tc�nl No. Additional CITY ��am p�Q ��Tel.No.&'G�•.� D
th�parmit fs for ono hundred dollon(SI00)or I�ss.)
I cnrlil 'hnl in Ihe e�fermnncr of Ihe werk for which this P�nN�MECK
Y � AP�ICANT
�ermil is issue�l,I sh�ll net employ ony rr.rson in any manner
so as�o F.ecnmr suhirct io itie Workers'Compensa�ion Laws. L�qh��n9 Fi�lurrs First 20 ADDRE55
To�al No. Addi�ional
CITY Tr.l.No.
Da'e nP{����a^� Fi.ed Appl�on<es No�Ove�1 hiP pEqy,i�
NOTICE TO AFPLICANT: If, of�er mnking Ihis Cerlificare oF APM��4NT y� �EG - --
ErPmption, yo� should F.Pceme subjec� io �he Workers' Ra^9e_Hea�er D.YJ._.
Comnertso�ion provis�o�s of Ihe(nbor Code,ynu mus�fonh- Ovon ,Drye. �y�r.p.1._ ACCRE55 j��Lc � E �
wl�h comply ith such pro�isions or ihis permil shall 6r. Top _FAU —V�.H.� CITY _� Tel.No.
deemed reveked. Hoad _Fnn _Othr.r_ �� �r� .
LICEN�D CO'dTRACTORS DECLA4ATION LiCF\:E OW
I hereby a!firm ihot I o�n licensed under provisions oi Chaptar 9 Disp. �Room Air Cond. _ rrEG.tvu.�nBFR� Q •� Class.
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(t�mmen;inq wiih Secr�on 7000)el D�v�sion 3 of Ihe Business paM,P�qnrnrotu5 8 lerge Applionces DISTRICT NO. PROCESSED BY O
and Profess�ons Cw.'e,ond my Gcense rs in full force ond eHeci. D
C � //� Sire.8 TyFe FiP,KW,KVA,or KVAR V
License Number / J Lic.Class� FINAL �
/ Up to 1 Incl. !.�^��S �
�G���/ ('L��C �/l�/�� Over 1 to 10 Incl. DATf� � ypLIDATION W
Conhncror Y�JO Date p�er 10 io 50 Incl.
� F"�rrnr� �-
I am exempt under Sec. Over SO to 100 Inc. BY U)
6.8P.C.icr this rcason ��n��� z
Servicr.s,Sw6d.,M,CC 8 Panelbonrds � ,._G G a 1 :�
�n�': 0-200 Amp.Under 600 V �
519nature 701•1000 Amp.Under 600 V ,_ e e e e�
❑ Over 1000 Amp.cr Over 6pp V
E.emp�ion io.Rep.Main�.EI=c�. � • • � �,�Q
S�NGIE FAM1l!LY Temp.Powe�Polp 8 App�rrerances • +
F�O.".+E ONJNfR�BUILDE4 DECLARATION � ° � •� ��'
Siqn wiih One B•anch C�rcuii
I h�re6y ef(irri Ihcl I om ezempl frem ttie Contreclor"s license ������anol$i n Branch Circuils ' ����� ��7
�aw{cr�he followin�reason(Section 7031.5, Business and 9
Profess�ons Code):
❑ I,os owner ef 1he.property,will do the work ond thr. M�sc.ConAuits 8 Conduc�ors
strucrure �s not imended or offr,red(or saie(Sect�on O'her(See Complete Fee Schedule�_ � ►
7044,Business and PrefPssions Code).
CONSTRUCTION LENDIhG AGENCY
I hereby a((irm ihaf Ihere.is o cons�ruction I�nding agency for
��e perlormanc�ef th?wo�k for which�his permir is issued pERM.IT FCE (Sub•Totol) `a
(Sac.9097.Civ.C.).
PLAN CHECKING FEE
\lender's Nome
PERMIT ISSUING FEE
Lendr.r's Address
�erhfy ihat I have rend Ihis npplico�ion and s�o'e ihot the TOTAL FEE
`•e iniarmoiien is correct.I ag•ee io comoly w�th nil County
'�tes and S�n�c I�ws rrc�uln�ing El�clrical wiring,and
•u�horir reArr,sentatives of fhis Couniy io en�er upon
men onr.d properry for inspeuion purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
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