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WORKERS'COMPENSATION�ECIARATION 76A663 i0i8t ApPEiCATtON FQR ELECTRICAL PERMIT
I hereby affirm �ho� I hove o reriiiicate of consent to self �-�' �
insure.or a certifimte ot Workers'Compensation insurance, GOUNTY OF LOS ANGELES BUILDING AND SAFETY
� or a cer�ified copy thereof�Sec.3800 tab�.JC.).
Policy No���1Fa�mpan��l.1f��n� ��`P FOR AiPUUHT TO HI.L IN DDRE55 � �
1 � Certified copy is here6y fvrnished. New Residential Bldgs.8 Pools EACH NO. fEE
� Os _ g LOCAUTY rn
Cenified copy is filed wilh�he couMy building inspeo- 1 8 2-Pamily,$q.Fi.
1 lion depo�finent. 1 � Mu��i-family Sq.Ft. ROSS ST.
�7n(�,� PP ���t G�.�`����� ResidenrwlSwimmingPoois FlRMNAME
� Oare LdE}�_1—A licant (f (� Y
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._ ��� /�,�
' COMPENSATION INSURANCE A�DRE55 ►`! ��
First 20 �
(Thls s�elion n�ad nol iro complN�d if th�work involv�d by To�al No. Additional CITY Tet.
Iho p�rmit is fo�one hund��d dollors(;100)or losa.) PLAN E
I certify�ho�in tha perfarmance of the work for which this A7ViICANT
� permrt is issued,1 shall nor employ eny person in any manner
so,r-�o bemme sobjact to the Workers'Compensation taws. �'9M��9 f�xtures First 2D _ ADORESS
� Additiorro4
� Totol No. CITY Tel.No.
D�te ApplicaM p�x�qpplionces Not Over t HV pERMIT 1 '
� �ICE TO AP�LICANT: if, after moking this Certificota of qVMIC4N7 �
..:mption, you sFould bemme subject to �he Workers' Ronge_Heater_D.W__
Compensa�ion provisions of ihe Lo6or Code,you must forth- Oven _Dryar _W.M.— A�DRESS
with comply wi�h such provis�ons or fhis permil shaif be Top —FAU —W.H.—
deemed revoked. Hood _Fan _Other_ CITY� , Tal.N �
IICENSED CONTRACTORS DEf1ARA110N uCE�uSE OR .�`, ,n!
t herehy pffi.m that�om licensed�nder provisions of Chapte�9 Disp. _Roam Air Cond _ REG.NUn�eER �i� �"! C�Ou•�.�G'7
commenci with Section 7000 of Division 3 of ihe&usiness DISTRICi NO- PROCE D BY
( R9 1 Power Apporatus 8 Large Appliances �
ard Professions Code,and my license is in tutl force and effeci.
'f Size&Type HP,KW.KYA,w KVAR C3
License Number Up to 1 fnct. FINAC
2.�,�Z��'"F7lk.Class d.'
JjhlZ,���� ,�� Over 1 io 101nc1. DATE ��G K VALIUATION �
l �s:1 �
co��.o��o�t/ t Over 10�0 50 Inci. FINAI
� I am exempt under Sec, Over 50 to 100 Inc. BY d
B.BP.C.for ihis reason Orer 100 Z s
Services,Swbd.,MCC 8 Panelboards �
Dote: p_ppp pmp.Under 60Q V
SignaWre 201-1000 Amp.Under 6W V
� Over 1p00 Amp.or Over 60p V
`xemption for Reg.Maint.E1ecr.
' SINGLE FAMILY Temp.Power Pole&Appurtenencea �'
j - , HOME OWNER-BUILDER DECLARATION giy��„ith pne&oncb CNcuil �
� 1�ereby affirm Ihat I om exempr from�he Confroctor's ticense Additional Si n nch Circu�,. _ �
Law for�he following reoson(Section 7031.5, Business ond ('���c�
Professions Code): � �C �Q$9�7 A
❑ I,as owner of the property,wili da�he work and the Misc.Canduits&Conductors
Other See Com lete Fee Schedule_ `���� � �2
structure is not intended or offered for sale (Sedion � P � �
7�44,Business and Professiom Codej. � � �3 a 5 Q
CONSTRUCTION LENDING AGENCY � ° ' n
1 hereby offirm that ihere is o mnstruUion lending ogenty for Q�2�����U
the performonce of�he work for which ihis permi�rs issued pERMIT FEE (Sub-Total) "
(Sec.3047,Civ.C.)-
PLAN CHECKING FEE
Lender's Ncme
PERMIT ISSUING FEE
Lender's Address
I certify tha�I have reod this application and stare that the TOTAL FEE
a6ove i�forma�io�is correct.I agree to comply with oll Coun�y
ordinonces and Slote laws regulating Electricol wiring,ond
hereby authorize represe�lotives of rhis Co�nty to enfer�pon
+he above-menrioned p�operry io� nspecnon urposes. SEE REVERSE FOR EXPLANATORY IANGUAGE I
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