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WORKERS COMPENSATION DECLARATION 76A663 10/91 APPLICATION FOR ELECTRICAL PERMIT
-I'heroEy affirm that I have a certificate of consent to self CE 806G
AAurb orb certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
ora certified copy thereof (Sec 3BOD Lab C )
P❑oliicy No Company FOR APPLICANT TO RLL IN ZRESS
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE
Certified copy is filed with the county building inspec I B 2 Family Sq Ft
y _ 5 LOCALITY
non department Multi-family Sq Ft — NEAREST
Residential Swimming Pools CROSS ST O
Date Applicant OWNER OR
FIRM NAME J OSC PlY 19 YyJ I I ER
CERTIFICATE OF EXEMPTION FROM WORKERS ' MAIL
Outlets Rec_Light_Sw
COMPENSATION INSURANCE ADDRESS ]"{s'7n L!e' L/rf4VQ
(This section need not be completed N the work Involved byFirst 20 CITY Tel No
the permit Is for ono hundred dollars ($100)or Ins ) Total No Additional 7'e 4 g1p .?
I certify that in the performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
iso as to become subject to the Workers Compensation Laws Lighting Fixtures First 20 ADDRESS
' f Total No Additional
Date L2 y-8 r Arplicam �rO , CITY No
NOTICE TO APPLICANT If aft makig this Certificate of Fixed Appliances Not Over I HP PERMIT
Exemption you should beco a subject to the Workers Range_ Heater_D W _ APPLICANT -
Compensation provisions of the Labor Code you must forth Oven _Dryer —W M _ ADDRESS
with comply with such provisions or this permit shall be Top _ FAU .—W H —
deemed revoked CITY - Tel No
Hood _ Fan _Other_
LICENSED CONTRACTORS DECLARATION Dt3 _ Room Air Cond LICENSE OR IBY
`
I hereby affirm that I am licensed under provisions of Chapter 9 p REG NUMBER d
(commencing with Section 7000) of Division 3 of the Business DISTRICT NO
and Professions Code and my license is in full face and effect Power Apparatus 8 Large Appliances �' Q
Size 8 Type HP KW KVA or KVAR U
License Number Lic Class FINAL
Up to 1 Incl C1
Connector Data Over 1 to 10 Incl DATE ` - '� VALIDATION F"
❑ Over 10 to 50 Ind FI W
I am exempt under Sec Over 50 to 100 Inc BY �'
fn
8 8P C for this reason Over 100 Z
Dote Services Swbd MCC 8 Ponelboords ► t
0 -200 Amp Under 600 V
Signature 201 - 1000 Amp Under 600 V '
Over 1000 Amp or Over 600 V
Exemption for Reg Mamt Elect ;13 6 Q 4
SINGLE FAMILY Temp Power Pole 8 Appurtenances • e r2� OS JqSr n0
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit • 2 e O yz
I hereby offvm that I am exempt from the Contractor's License Additional Sign Branch Circuits ( LSO r
Law for the following reason (Section 7031 5, Business and
Professions Code)
® 1 as owner of the property will do the work and the Mac Conduits 8 Conductors
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ► '
7044 Business 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 PERMIT FEE ' (Sub Total)
(Sec 3097 Civ C )
PLAN CHECKING FEE -
Lender s Name
PERMIT ISSUING FEE (� O
Lender s Address' S SO
I certify that I have read this application and state that the TOTAL FEE,
above information is correct I agree to comply with all County
ordinances and State laws regulating Electrical wiring and
hereby authorize representatives of this County to enter upon t
the above mentioned property for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Sign ure of ermines Date