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WORKERS COMPENSATION DECIARATION 76Ae63 IOi81 qpp��CATlON FOR ELECTRICAL PERM,� J �
I hereby offirm tha� I hove o cerlifim�e of consen�b self CE-8p6G `
insure,or a cerrificate af Workers'Compensation Insurance, COUNTY OF LOS ANGELES Bl11LDiNG AND SAFC�Y'�--�'
o�a�cer�ifi d copy ihereof($ec.3800,Lab.C.)
V❑olicy No`��Omppny�NOI/S.I��/�� FOR APPUCANT 70 FILL IN JOB p ,(" I
Certified co s hereb fumished. EACH NO. FEE ADDRE55 7 tJ
�-7 PY' Y //�. New Residential Bldgs.8Po I l
�y� Certified copy is filed with the county building insper �8 2-Family,Sq.F�. '^� � s — s Q �0��� �p� /_ i
"���' � depa tmenr. Multi-family$q.FI. CRO55 ST. .
�� Residential$wimming PooVs OWNER OR „`O"� `
Dnte Applican
FIRMN 1V �/�•'
CERTIfICATE OF EXEMPTION FROM WORKERS' Outiets:Rec,_light_.Sw._ � �"��
COMPENSATION INSURANCE F,5 p ADDRESS • , X
(TMIa aocibe npd�wf be tumpleled if fhe work tnvolrad by To�al No. Addilional ��T (f il/Q ��j�o�. Tei.No.�j 7�Y�,/
Nw ponnil k{or on�hu�rad daNan(5100)or lets.) vIAN CMECK
1 cer�iiy thai in the performnoce of�he work for which this qpp���Nf
permit is issued,1 shall nol employ any person in qny monner ,
so as to become subjett to fhe Workers'Compensation laws_ Lighting Fiz�ures First 40 ADDRE55
iatal No. �ditionol
CITY Tel.No.
�ate °pplican� Fixed Appliances Not Over I HP
IOTICE TO AhPLICANT: If, after moking thia Certifiea�e of APpM�GM�i f' C` t ��C
l aemption, you shoutd become sv6iect to �he Wcrkers' Ra�ge_Heater_D.W._
Compensation provisions of the La6or Code,yau must forth- Oven _Dryer _W.M._ ADDRE -(�, �/ ���
wi�h mmply wilh such provis�ons or this peimit sholl be Top _FAU _W.H._
deemed revoked. CITY �� ���(� Tel.No���(.j �
IICEN$ED CONTRACTORS OECLARATION Hood _Fon �O�her_
Disp. .___Room Air Cond. — ���E�� Class�� �
I hereby afflrm thaf 1 om licensed under provisions af Chapier 9 REG.NUMBER U
(wmmencing with Section 7000�of Dfvision 3 of the Business Power Appo�atus&Lorge Applionces DISTRICT NO. PROCFSSED BY 0.
ond Professions Code,aad my license is in full for�e and effect. +� O �
��y//y/����q� ,Q � Size 8 Type HP,KW,KVA,o�KVAR � d '(�ci`o n � €
License Number__�'�Lic Class fINAL �
/� Up to 7 Incl. �
�/�`Z?/C��,� � Ouer 1 to 10 tncl. DA� 3-�U- VALI�ATION � �
Conhocror Date
❑ Over t0 l0 50 Incl. FINAL � / W t
1 am exemp��nder Sec. Over 50 fo 100 Inc. BV �--Y �- �
B.BP.C.far this reason Over 1W 0 �
Z' t
pa�e: Services,Swbd.,MCC 8 Ponelboards :
0-200 Amp.Under 6W V � �� ��l;-� 1�. �
Signature 201-1000 Amp.Under 6W V
❑ Over IQQO Amp.or Ouer 600 V n s o c . . � �
Exemprion for Reg.Maint.Elect.
I E 1 1 `_.f: ':,
S�NGLE FAMILY Temp.Power Pofe 8 Appur�enances �� ��
� HOME OWNER-BUIL�ER DECIARATION Sign with One Bronch Circuit s c• � . � � ,
�ere6y affirm thar t om exempt from the Co�tmnor's License qdditional Sign Branch Circails , , �
' taw for the fol�owing reason(Section 7031.5, 8usiness and (i Y'.L c-''- '
Professions Godej� " !
❑ I,as owner of the property,will do the work ond the Misc Conduits 8 Conductors �
sirotlure is noi intended or offered for saie(Section Other(See Comp�ete Fee Sthedule)_ � �
7044,Bosiness ond Profeuions Code). �
CONSTRUCTION LENDING AGENCV
I hereby affirm that there is a conslruclion lending agency for �
the performonce of the work for which rhis permir is issued p�RMiT FEE (Sub-7oto1) 3
(Sec.3097,Civ.C.).
PLAN CHECKING fEE �
Lender's Name
PERMIT ISSUING FEE
Lender's Address //
!certify thoi!hove reod this applicalion ond s�a�e thot ihe 70TAL fEE �
above infwmation is ronecL I agree to mmply with all Couniy
ordmonces and S�ate laws reg�latinq Eledriml wiring, vnd I
hereby outhorize representotives of this Co�nty to enter upon I
the ave-mentioned propeHy for inspech p poses. �
� SEE REVERSE PQR EXPIANATORY LANGUAGE �
Signature of Permittee ���
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