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•-- WORKERS'COMPEN5ATIONDECLARATION 76A663 APPI.iCATION FOR ELECTRICAL PERMIT �
CE$OBG 12-801
l herebv affirm that I have a certificate 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 � FOR APPLICANT TO FILI iN JOB /1 �- �,c �D, f
� PolicyNo. Company�'�'�'"'`"`� •���'-''"'"� EACH NO. FEE ADDRESS�G��''J �i-'�"wL /'C��`�c
�> . New Residen[iai Bldgs.&Poala
Cenified coyy is hereby tumished. � . 1&2•Pamily,5q.Ft. $ _ � LOCAU7Y �'�`-
���� Multi-familySq.Ft. CROSSST � �'�s�4d �"('�
�CertiCied copY is tiled wjth the counly building inspection ReSidential Swimming Pools / �y/
department. 7 FiRM NAME / ��-f/�'
Date '1!���ARPll�a�� - ���• _- . Outlets:Rec.LLight Sw._ � MAII '/
—�iist 20 AODAESS �T�
CERTIFICATE OF EXEMPT[ON FROM WORKkRS' Total No. Additional cITV � Yel No.�� }
COMPENSATION INSURANCE PLAN CHECK �� �
� APPLICANT V
(1Lis section need not be compteted iE the woric imolved Lighting Fixtures First 20
by the peimit is [or one hundred doilus(SI00)or lcsa.) ADDflES3 (��p3(,� p�
Totai No. Additianal �(
I certify that in ihe pe�fo�mance of the work for which this Fixed Appliances Not Over 7 HP CITY Te�No.�� J �
� permit is issued,1 shall noi employ any persan in any manner PERMIT , �/1 {y�
so as to hewme subject to the Workers'CompensaCvon Laws. Ram�e_Heater_Q.W.! . APP 1 AN7 % C 7 � �
Oven _Dryer_,W.M._ qDDRESS �� ,'3G � ?
Date ARplicant T°P--FAU _W.H..� CITV Tei Na.�j�
� Hood_Fan —Other�
NOTfCE TO AYYLICANT:)f,etter makin;this Certificate of Disp. _Room Air Cond.` _ LICENSE OR � .L �I
Ezemptiun, you shoutd becom� rubjeet�to 1He� Workers' REG.NUMeER 4% - � Class
Cortpensation prorisivas oC the Labar Code,you�must torlh• Ppwer Apparatus&Large Appliances 0157RICT NO. PROCESSED Bv
� 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
Over 1 m 10 Incl. aATE � �a/�p?, VAUDATION
LICENSED CON2RACTORS DECLARATION Over 10 to 50 Incl. - . _ �
1 hereby affirm that I am licensed under provisions of Chapter Over 50 to 700 Inc. _ gV AL •
9 (commmcing with Section 7000)of Divesion 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�/ �
� / � �(� 201-t00Q Amp.Under 600 V t�
Contrador4���L�+� Date ��/"/�D Over 1000 Amp.or Over 600 V J��
(! t
HOME OWN�R-BUILDER DECGARATION Temp.Pawer Pole&Appurtenances �
� I hereby affirm that 1 xm exempt from the Conuactor's Sign with One Branch Cirwit 3
License Law for the tollowing reason (Section 7031.5, Busi- Addit7anal S�gn Branch Circuits �
, ness and Profesxionc Codo): �
Misc.Canduits&Conductors �
� i, as owner.ot the propertY.'.'��11 do.tlte work and the � pther(See Complete Fee Schedule)—
� structure is not intended or offered tor sale (Section
7044,8usinnss artd Prntessions Code).
CONSTKUCTION LtiNDING A(.ENCY E
I he�eby affirm that tAere is a const[uction lending agency 1
for tbe performanee a[ [he,,Jrr work for which [his permit �s pERM1T FEE (Sub•Totat� � � L� �i n��H �
issued(Sec.309T,Civ.G1J�1L �
Lender's Name ��� �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 �f. f i• • � 2,�(i�
�:s6�ve ioformation is corroet.1 agree to comP1Y�th a!I Connty �
��ordinances and State laws regutating Electricaf wtrtng, and ' Q 7,� ����
!hereby authodze represeniative�of this CountY to enter upon
[the abo�- eMi��ed D�opa��Y for inspection purposea. SEE�REVERSE FOR EXYLANATORY LANGUAGE
."� � '
Signature of Permittee D e
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