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WORKERS'COMPENSATIONDECLARATION 76A663
6 63 (2801 APPLICATION FOR ELECTRICAL PERMIT
76
I hereby affirm that 1 have a certificate of consent to self COUNTY OF.L NGE LES BUILDING AND SAFETY
insure, or a certificate of Workers'Compensation Insurance,or .
a certified copy thereof(Sec. 3800,Lab.C.)
p } FORA (CANT TO LIN ADDRESS
Policy No. Com an
New Residential Bldgs. &Pools EACH NO. FEE
Certified copy is hereby furnished. - 1 &2-Family,Sq. Ft. $ — 5 LOCALITY
❑ Multi-family Sq. Ft. — NEAREST
Certified copy is filed with the county building inspection CROSS ST
Residential Swimming Pools
department. OWNER OR
ryry-// FIRM NAME
Date Applicant Outlets: Rec."Kight� Sw. r�� a MAIL
// First 20 ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No._J_y� Additional CIT Tel No. L�
COMPENSATION INSURANCE
PLA CHEW
CL
O
(This section need not be completed if the work involved ;,.46_,APPI_ICANU
by the permit is for one hundred dollars ($100) or less.) Lighting Fi xture� First 20 ADDR
Total No.
�EJL Additional
1 certify that in the performance of the work for which this CITY Tel No. l-
Fixed Appliances Not Over 1 HP
permit is issued, !shall not employ any person in any manner PERMIT
so as to become subject to the Workers' Compensation Laws. Range_ Heater_D.W. APPLICANT W
Oven _ Dryer_W.M. ADDRESS - N
Z
Date Applicant Top FAU _W.H. —
Hood — Fan _Other_ - CITY Tel No.
NOTICE TO APPLICANT: If, after making this Certificate of Disp. _ Room Air Cond,_ LICE
Exemption, you should become subject to the Workers' REG.NUMBER Class
Compensation provisions of the Labor Code, you must forth- Power Apparatus& Large Appliances DISTRICT NO. PR eY
with comply with such provisions or this permit shall be
Size&Type HP,KW, KV A,or KVAR
Up to 1 Inc].
deemed revoked. (25;/
FINAL
Over 1 to 10 Incl. DATE VALIDATION
LICENSED CONTRACTORS DECLARATION Over 10 to 50 Incl. .
I hereby affirm that 1 am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000) of Division 3 of the Busi- Over 100 BY
ness and Professions Code, and my license is in full force and
effect. Services
License Number Lic. Class 0-200 Amp. Under 600 V
201-1000 Amp. Under 600 V
Contractor Date Over 1000 Amp.or Over 600 V /+ ///
HOMEOWNER-BUILDER DECLARATION `-�
Temp. Power Pole& Appurtenances '(
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's /
License Law for the following reason (Section 7031.5. Busi- Additional Sign Branch Circuits
ness and Professions Code):
Misc.Conduits& Conductors
V I, as owner of the property, will do the work and the Other ISee Complete Fee Schedule)— - -
structure is not intended or offered for sale (Section
7044, Business and Professions Code). 1 6j7.5 A
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agencv # 0 0 o e o 2
for the performance of the work for which this permit is PERMIT FEE (Sub-Total) /V "d
issued (Sec. 3097,Civ.C.). Z:o o 17.00
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address 0 0 0 13,Q Q
PERMIT ISSUING FEE
j 0912-80
I certify that I have read this application and state that the TOTAL FEE
above information is correct.1 agree to comply with all County
ordinances and State laws regulating Electrical wiring, and
hereby authorize representatives of this County to enter upon
9�;�
pection purposes.. SEE REVERSE 17OR EXPLANATORY LANGUAGE
ss-/a ,Ll
6/signature of Permittee Date