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r WO.XY_ COMPENSATIONDECLARATION t CE8 6G (2 80) APPLICATION ,FOR ELECTRICAL PERMIT
I hereby affirm that 1 have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY
insure or a certificate of Workers Compensation Insurance or ,
a certified copy thereof(Sec 3800 Lab C)
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FOR APPLICANT TO FILL IN JOB
Policy No Company r r EACH NO FEE ADDRESS~ zdl r Ja
❑ New Residential Bldgs &Pools
Certified copy is hereby furnished 1 &2 Family Sq Ft $ '— Is LOCALITY
❑r Multifamily Sq Ft - ' — NEAREST
Certified copy is filed with the county building inspection CROSS ST
department # Residential Swimming Pools 4 3 OWNER OR
FIRM NAM
Date Applicant Outlets Ret�Light Sw . ADDRESS
First y
i CERTIFICATE OF EXEMPTION FROM WORKERS . Total No �— Additional CIT Tel No } I
i COMPENSATION INSURANCE fL ,
PL C �( O
`(This section need not be completed if the work involved : APP L I N T \ V
Lighting Fixtures First 20
by the permit is for one hundred dollars ($100) or less) g ADDRESS
Additional
Total I certify that in the performance of the work for which this Fixed Appliances Not Over 1 HP CITY el No $ V
i permit is issued I shall not employ any person in any manner PERMIT11
so as to become subject to the Workers Co ensatio Laws Range_Heater D W APPLICANT VV 4 CL
s Oven _ Dryer W M o ADDRESS o * to
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rDateWCEO
Applica r Top _ FAU a—W H _
Hood Fan _Other_ CITY TeI,No
NOTPLICANT If after making this Certificate of Disp _ Room Air Cond` LICENSE OR
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 PROC SS BY
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with comply with^such provisions or this permit shall beOY
deemed revoked ' �Size&Type HP KW KVA or KVAR --
( I I Up to 1 Incl u FINAL `
LICENSED CONTRACTORS DECLARATION Over 1 to 10 Incl DATEZY VALID ION `
Over 10 to 50 Incl '
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc FINAL f
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 2 8 5 9 A
Contractor r Date Over 1000 Amp or Over 600 V
# • • . • • 2
HOME OWNER BUILDER DECLARATION Temp Power Pole&Appurtenances ) • * 3a75'
ii
I hereby affirm that I am exempt from the Contractorsa Sign with One Branch Circuit �
Additional Sign Branch Circuits
License Law for the following reason (Section 7031 5 Busi • - o o • -3a755
�
ness a Professions Code) + N r `
Misc Conduits&Conductors i` i 0 a 0 5,-8 5
I as owner of the property will do the work and the Other (See Complete Fee Schedule)—
structure is not intended or offered for sale (Section
7044 Business and Professions Code) i r , y
CONSTRUCTION LENDING AGENCY ; r
I hereby affirm that there is a construction lending agency "
for the performance of the work for which this permit is , 4
PERMIT FEE
issued(Sec 3097 Civ C) r s r (Sub Total)
Lender s Name PLAN CHECKING FEE (One Fourth Permit Fee)
Lender s Address PERMIT ISSUING FEE U
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I certify that I have read this application and state that the TOTAL FEE J
above information is correct I agree to comply with all County
ordinances and State laws)regulating Ele trical wiring and a -
hereby authorize repres
oned entat s of�this my to enter upon L r
thea a mentirop for inspe n pu oses
SEE REVERSE FOR EXPLANATORY LANGUAGE t ,
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Signature mit ate