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WORKERS'COMPENSATION DECLARATION 17GAW 10/81 APPLICATION FOR ELECTRICAL PERMIT
1#,i'.by affirm that I have a certificate of consent to self ICE-8066, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
certified copy th�ere0 (Sec. 38000,,Lab. C.) i I
policy No.�—��1C.Mpany v rerte 6)0,97 FOR APPLICANT TO FILL IN FJOB
❑. Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE ADDRESS "Te/n e
�j 1 &246mil S Ft. $ = $ LOCALITY
I f�J Certified copy is filed with the county building inspec- Y. q•
tion department. Multi-family Sq. Ft. NEAREST a, ^
P CROSS ST. A sT�/ter TTS f2
Residential Swimming Pools OWNER OR
Date Applicant FIRM NAME.4aa6l1!el veca !-
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE ADDRESSJ!" a! �1 S v F}b IJP
(This section need not be completed If the work involved by Total No. AdditFirsttiional CITYT—! z feel Tel. No.a����3p0
the permit is for one hundred dollars($100)or less.)
I certify that in the performance of the work for which this PLAN CHECKAPPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the-Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. �_ Additional CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP
NOTICE TO APPLICANT: If, after making this Certificate of PERMIT
Exemption, you should become subject to the Workers' Range_ Heater_D.W. APPLICANT $
Compensation provisions of the Labor Code, you must forth Oven Dryer —W.M.— ADDRESS a .1y@ ��
with comply with such provisions or this permit shall be Top _ FAU —W.H. —
deemed revoked. CITY �S 414 � ,5� Tel. IVod{(p�j/t'�pQ
LICENSED CONTRACTORS DECLARATION. Hood _ Fan _Other_
'LICENSE OR 1(�/Q
I hereby affirm that I am licensed under provisions of Chapter 9 I D.isp. — Room Air Cond. REG.NUMBER 01ft/0Class
(commencing with Section 7000)of Division 3 of the BusinessDISTRICt NO. PROCESSED BY
and.Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances CL
'-
Size&Type HP, KW, KVA, or KVAR- _ O
License Number 0?01'1/v`f Lic..Class Q-1QA 1FINAL r 111Up to 1. Incl. DATEIX /�— 09
Over 1 to 10 Incl. VALIDATION
Contractor&&-QU 6=;C—S Date11—
❑ Over 10 to 50 Incl. FINAL /-
I am exempt under Sec. Over 50 to 100 Inc. BYa, �s-A,V / +'�'
B.&P.C. for this reason Over 100 1A
Date: Services,Swbd., MCC&Ponelboards , e
0 =200.Amp. Under 600 V
Signature 201 - 1000.Amp. Under 600 V G r 5 t' P
Over 1000 Amp. or Over 600 V
F] ,
Exemption for Reg. Maint. Elect. c 0 0 0 0
SINGLE FAMILY Temp. Power Pole&Appurtenances n. o
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit C
I hereby affirm that I am exempt from the Contractor's License
Law for the following reason (Section 7031.5, Business and Additional Sign Branch Circuits n 0
Professions Code): l
❑ I, as owner of the property, will do the work and the M.sc. Conduits&Conductors
structure is not intended or offered for said (Section Other(See Complete Fee Schedule)_ Poo
7044, Business and Professions Code).
CONSTRUCTION LENDING AGENCY I
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.). O
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING,FEE
Lender's Address
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 4
hereby authorize representatives of this County to enter upon ;
the above-mentioned property for inspection purposes. (I SEE REVERSE FOR EXPLANATORY LANGUAGE
s y,
Signature of Permittee. Date