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•-- WORKERS'COMPENSATIONDECLARATION 76A663 ppp�,�CATION FOR ELECTRICAL PERMIT �
CE$O6G 12-801
l herebv affirm that I have a rertificate of consent to sel£ COUNTY OF LOS ARIGEL6R BUILDING AND SAFETY
insure,or a certificate oi Workers'Compensatlon ineurance,or
. a certified copy thereof(�c.3600,#.eb.C.1
,;,�p�y_c,���,s �j J � FOR APPLICANT TO FILI iN JOB 1,f� �
{ PolicyNo. Company��"""� "-Lt'-"""� EACH NO. FEE ADDRESS.�ClG�G��''� �i-��'�L ��`�
�> " . New Residen[iai Bldgs.&Poala
CeniYied coyy is hereby tumished. � 1&2•family,5q.Ft. $ _ $ LOCAUTY �'�`—
���� Multi-family Sq.Ft. CROSS ST � �'�vG� �'�"�`{'�
�CertiCied copy i�tiled wjth the counly building inspection ReSidential Swimming Pools
department. � OWNEROR � t/�!Y
Date��hA� licant - �v�✓�. FIRM NAME �-«'
FP Outlets:Rec.LLight Sw._ � MAII '/
� —�iist 20 AODAESS T �
CERTIFICATE OF EXEMPT[ON FROM WORKk:RS' Total No. Additional c�TV � Te�No.�� }
COMPENSATION INSURANCE PLAN CHECK G� 0
� APPLICANT V
(1Lis section newl not be compteted iE 1he woric imolved Lighting Fixtures First 20
by the peimit is [Or One hUndred dollus($100)or Itsa.) ADDflEss (��p3(,� p�
Totai No. Additional �(
I certify that in the pe�formance of the work for which this Fixed Appliances Not Over 7 HP CITY � Tel No.'�� / �
� permit is issued,1 shall noi employ any persan in any manner PERMIT , �/1/1��n {y�
so as to 6ecome subject to the Workers'Compensation Laws. Ram�e_Heater_D.W._ APP 1 ANT - C 7�`7�'v �
Oven _Dryer_,W.M._ qDDRESS �� ;3G � ?
Date ARplicant ToP.._FAU _W.H..� CITV Tei Na.�j�
� Hood_Fan —Other�
NOTICE TO AYYLICANT:)f,etter makinE this Certificate of Disp. _Room Air Co�d.` _ LICENSE OR � .L /I
Ezemption, you shoutd becom� rubjeet�to 1He� Workers' REG.NUMeER 4% - � Class
Compensation prorisivas o[tha Labur Code,yoa�must torlh• Ppwer Apparatus&Large Appliances 0157RICT NO. PROCESSED ev
� with comply with such provisions or this permit shall be Size& Ype HP,KW,KVA,or KVA � �
deemed revo[ced. � Up to f Incl. � f L ����
FINAL
QV¢f 1 t0101nc1. DATE � /a/6�' VAUDATION
LICENSED CON2RACTORS DECLARATION Over 10 to 50 Incl. � - . _ �
t hereby affirm that I am licensed under provisions of Chapter Over 50 to 700 Inc. _ gV AL •
9 (commencing with Section 7000)of Division 3 of the Busi- Over 100 !
{ ness and Professions Code,and my license is io fukl focee unJ �� . �
� effect. / Servicea -/
• License Number� -4 ���� Lic.Clase �' �'2�'�p'..V^�r 600.V ,y�/ �
/'/ �(�X 201-t00Q Amp.Under 600 V v�
Contrador4�'V��� Date ��,"/"a Over 1000 Amp.or Over 600 V J��
(! t
HOME OWN�R-BUILDER DECGARATION Temp.Pawar Pole&Appurtenances �
� I hereby affirm that 1 xm exempt from the Conuactor's Sigrt with One Branch Circuit �
License Law for the tollowing reason (Section 7031.5, Busi- Addit7onal S�gn Branch Circuits
, ness and Profeszionc Code): �
Misc.Conduits&Conductors �
� i, as owner.of the_propertY.'.'��11 do_tlte work and the � pther(See Complete Fee Schedule)—
� structure is not intended or offered tor sale (Section
7044,8ueinesq and Protessions Code).
CONSTKUCTION LtiNDING A(.ENCY E
1 fie�eby affirm that tAe�e is a const�uction lending agency 1
for tbe performance a[ [he work for which [his permit �s pERM1T FEE (Sub•Totat� � � L� �i Q�C H �
issued(Sec.309T,Civ.GI�11— �
Lender's Name ,.�1� �1 pLAN CHECKING FEE (One-Fourth Permit Fee) � �• • • • •�
LendePs Address pERMIT ISSUING FEE �CU , � • ° � L "rJ l� �
I certity that L have read�this application and state that the TOTAL FEE �fI �i• • � z,�(`�
�:s6�ve information is corroct.1 agree to comP1Y�th a!I Connty �
,rordinances and State laws regutating Electricaf wtrtng, and ' Q 7,� ����
Ihereby authodze represeniative�of this CountY to enter upon
[the abo�- eMi�ed D�o{���Y fot inapection purposea. SEE�REVERSE FOR EXYLANATORY LANGUAGE
� i x '
Signature of Permittee D e
O 4 O� 01
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