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WORKERS'COMPENSATION DECLARATION 76-663 10/81
CE-806G APPLICATION FOR ELECTRICAL PERMI1
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I hereby affirm that I havt-.Ncertif�; of consent to selfinsure,
or a certifi t of Wgrkers' Compensation Insurance, or a certified_ COUNTY-OF LOS ANGELES BUILDING AND SAFETY
copy Tereof�.3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN JOB
❑ Certified copy is herebyfurnished... EACH NO. FEE ADDRESS SI J
New Residential Bldgs.& Pools
❑ 1 & 2-Family,S Ft. $ — $ LOCALITY
Certified copy is filed with the county building inspection Y. q�
department. Multi-family Sq.Ft. NEAREST
CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR ,cam
CERTIFICATE OF EXEMPTION FROM WORKERS' FIRM
Outlets:R� Light,6 S11.1 y MAIL
COMPENSATION INSURANCE" (/ ADDRESS r
(This section need not be completed if the work involved by the First 20
permit is for one hundred dollars($100)or less.)
Total No. Additional 0 CITY Z �C— Tel.No.
I certify that in the performance of the work for which this permit PLAN CHECK
APPLICANT
is issued, I shall not employ any person in manner as to
become subject to the Workers'Co
ens Lighting Fixtures First 20 ADDRESS
��fG� {�j Additional
o ' Total No. CITY Tel.No.
Date ApplicanFixed Appliances Not Over.1 HP PERMIT , �C
NOTICE TO APPLICANT: If, "apeon
Cerf' e of APPLICANT�.i✓®�a��,� �j� G�//6��i'
Exemption,you should become subject to the Workers'C �nsation Range_ Heater_ D.W.
provisions of the Labor Code, you must forthwith com ly with such Oven _ Dryer _ W.M. _ ADDRESS �j� �����
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _ ✓5 •4p
��i p
CITY � �� /� o 39' _3Tel.N
LICENSED CONTRACTORS DECLARATION Hood — Fan Other_
herebyaffirm that am licensed under provisions of Chapter 9 LICENSE OR [''�
p -Disp. — Roam Air Cond. REG.NUMBER /. Classe
(commencing with Section 7000) of Division 3 of the Business and
Professions Code,and my license is in full force and effect. DISTRICT NO.: ��A PROCES BY
Power Apparatus& Large Appliances y(u
Size& Type HP,KW,KVA,or KVAR O
License Number / �✓� Lic.Class Up to 1 Incl. FINAL ca /� U
Contract vol. re G� e /fid -2, —�2 Over 1 to 10 Incl. DATE ��n �/� VALIDATION 0
❑ Over 10 to_50 Incl. [/ ( 0
I am exempt under Sec. Over 50 to 100 Inc. BY AL
B.&P.C.for this reason
Over 100 f1.
Service �-PaRelbp�rdsZ
Date: - 00 Amp_Uader_Cz00_V/ o ,
Signature 201 - 1000 Amp.Under 600 V 2$2 7,Q
❑ Over 1000 Amp.or Over 600 V 0 0 0 0;0
Exemption for Reg.Maint.Elect. 1 .0 0 5 1 Jr Q
SINGLE FAMILY Temp.Power Pole& Appurtenances
HOME OWNER-BUILDER DECLARATION o o 0
Sign with One Branch Circuit Jr 1.5 Q v
I hereby affirm that I am exempt from the Contractor's License Law
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits
Code): 1103 8 7
❑ I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) ,
and Professions Code).
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, PERMIT FEE (Sub-Total)
Civ.C.). 01
PLAN CHECKING FEE
Lender's Name 0
PERMIT ISSUING FEE �.
Lender's Address
I certify that. I have read this application and state that the above TOTAL FEE (J
information is correct.I agree to comply with all County ordinances
and State laws re ' County ting Electrical wiring, and hereby authorize
representative t nter on the above-mentioned
property ins ur S.
SEE REVERSE FOR EXPLANATORY LANGUAGE
nature of Per dtee Date