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WORKERS'COMPENSATION�ECIARATION 76A663 i0i8t ApPEiCATtON FQR ELECTRICAL PERMIT
I hereby affirm �ho� I hove o re.iiiicate of consent to self �-�' �
insure.or a certifimte ot Workers'Compensation insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
� o�a certified copy thereof�Sec.3800 tob�.}C.).
Policy No���l�mpan��yf��n� ��`P FOR AiPUCAHT TO Hlt IN DDRE55 � �
1 � Certified copy is here6y furnished. New Residential Bldgs.8 Pools EACH NO. fEE
� Os _ g LOCAUTY rn
Cenified copy is filed wilh�he couMy building inspeo- 1 8 2-fomily,$q.Ft.
� ron depo.rment. +� � Mu��i-family Sq.Ft. — RO55 5T.
—ei�— PP {�I�LLf r.l.��1Y"��(l7h Residenrwl Swimming Poois FlRM NMnE
� Oate A licani
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec_Light_Sw._ ��� /�,�
' COMPENSATION INSURANCE A�DRE55 ►`! ��
First 20 �
(Thls s�elion nwd nol iro eomplN�d if th�work involv�d by To�al No. Additional CITY Tet.
Iho p�rmii is fo�one hund��d dollors(;100)or losa.) PIAN E
I certify�ho�in tha perfarmance of the work for which this A7ViICANT
� perm�r is issued,1 sholl nor employ eny person in any manner
so,r-�o bemme sobjact to the Workers'Compensation taws. li9Ming fixNres First 2D _ ADORESS
� Additiorro4
� Totol No. CITY Tel.No.
D�te ApplicaM p�x�qpp(ionces Not Over t HV pERMIT 1 '
� �ICE TO AP7LICANT: if, after moking this Certificote of qVPLIC4N7 �
..:mption, you should bemme subject to �he Workers' Ronge_Heater_D.W__
Compensaiion provisions of ihe Lo6or Code,you must forth- Oven _Dryar _W.M.— A6DRE55
with comply wi�h such provis�ons or fhis permil shoil be Top —FAU —W.H.—
deemed revoked. Hood _Fan _pther_ CITY� , Tal.N �
IICENSED COSJTRACTORS DECLARATION uGENSE OR .�`, /��
t herehy dffi.m that�om licensed�nder provisio�s of Chapte�9 Disp. _Roam Air Cond. _ REG.NUn�eER �i� �! C�Ou•t.�G'7
commenci with Section 7000 of Division 3 of the Business DISTRICE NO- PROCE D BY
( M3 1 Power Apporatus 8 Large Appliances �
ord Professions Code,and my license is in tutl force and effeci.
'f Size&Type MP,KW,KYA,w KVAR C}
License Number Up to 1 fnct. FINAC
2.�,�Z,��'"F7lk.Class d.'
Jjh��.,�j�f� ,�;1���7 Over 1 io 101nc1. DATE ��G K VALIUATION �
� �:� �
co��.o��o�t/ Over 10�0 50 Inci. FINAI
� I am exempt under Sec, Over 50 to 100 Inc. BY d
B.BP.C.for ihis renson Orer 100 Z ;
Services,Swbd.,MCC 8 Panelboards �
Dote: p_ppp pmp.Under 600 V
SignaWre 201-1000 Amp.Under 6W V
� Over 1Dp0 Amp.or Over 60p V
`xemption for Reg.Maint.E1ecr.
y�' SINGLE FAMILY Temp.Power Pole&Appurtenencea �'
/ - , HOME OWNER-BUILDER DECLARATION giy��„ith pne&oncb CNtuil �
� 1�ereby affirm Ihat I om exempr from�he Confroctor's ticense qdditional 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 � �
7044,Business and Professiom Codej. � � �3 a 5 Q
CONSTRUCTION LENDING AGENCY � ° ' n
1 hereby offirm that ihere is o mnstruUion lending ogency for 0�2����U
the performonce of�he work for which ihis permi�rs issued pERMIT FEE (Sub-Total) "
(Sec.3097,Civ.C.)-
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify tho�I have reod this application and stare that the TOTAL FEE
a6ove i�fwma�io�is correct.I agree to comply with all Coun�y
ordinonces and Slote laws regolating Electricol wiring,ond
hereby authorize represe��otives of rhis Co�nty to enfer�pon
the above-menrioned p�operry io� nspecnon urposes. SEE REVERSE FOR EXPLANATORY LANCaUAGE I
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