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WORKERS COMPENSATION a TION DECLARATION CE 863 10/81 t ' APPLICATION FOR ELECTRICAL PERMIT
aff;R4''th�at I have a certificate of consent to self CE 806G k
Irrsure or'o certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
s or a certified copy thereof (Sec 3800 Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB /� t
I
Certified copy is hereby furnished New Residential Bldgs 8 Pools EACH NO FEE ADDRESS G S 1
$ LOCALITY—
Certified copy is filed with the county building m 1 & 2 Family Y S 9 Ft $
tion department Multi family Scl Ft — NEAREST
Residential Swimming Pools CROSSST
OR
Date Applicant
FIRM NAME IWO R6Q MIM
CERTIFICATE OF EXEMPTION FROM WORKERSOutlets Rec LighiP' Sw 3 MAIL
_ l
COMPENSATION INSURANCE+ ADDRESS
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(This section need not be completed if the work involved by Total No First 20 _ �? _ CITY Tel NA�(� 7
o
the permit is for one hundred dollars ($100)or less ) Addition6l
r PLAN CHECK
_1 certify that in the performance of the work for which this APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the orkers Compensation Laws Lighting Fixtures First 20 ADDRESS
A
° Total No �� Additional AA
Date K!TApplicant CITY Tel No
NOTICE TO APPLICANT If after making this Certificate of Fixed Appliances Not Over 1 HP PERMIT ki
Exemption you should become subject to the Workers Range_ Heater_DW _ APPLICANT
Compensation provisions of the Labor Code you must forth Oven _ Dryen _ W M — ADDRESS
with comply with such provisions or this permit shall be Top _ FAU —W H —
deemed revoked Hood Fan _Other_ CITY Tel No
LICENSED CONTRACTORS DECLARATION LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 Disp _ Room Air Cond REG NUMBER Class
(commencing with Section 7000) of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO U4r PR OC BY CL
and Professions Code and my license is in full force and effect Q
Size 8 Type HP KW KVA or KVAR � � U
License Number Lic Class Up totI Incl /
FINAL
Over 1 to 10 Incl DAT V DATION
Contractor Date
Over 10 to 50 Incl FI W
I am exempt under Sec Over 50 to 100 Inc B � /2
B&P C for this reason Over 100 Z
Date Services Swbd MCC & Panelboards
0 200 Amp Under 600 V t$416 vv
Signature 201 1000 Amp Under 600V
Over 1000 Amp or Over 600 V
Exemption for Reg Maint Elect
SINGLE FAMILY Temp Power Pole &Appurtenances
HOME OWNER BUILDER DECLARATIONS+� Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contracto�,ss License Additional Sign Branch Circuits
for the following reason (Section 7031 5 Business and
Profess Code)
as owner of the property will do the work and the Misc Conduits& Conductors 3 6 Q 8 A
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_ ® # 0 0 0 0 o 2
7044 Business and Professions Code) J 0 0 6 1 5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for o 0 0 6 1 5 0 55
the performance of the work for which this permit is issued PERMIT FEE (Sub Total) ( 206-85
(Sec 3097 Civ C ) 'I') oil
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
hereby authorize representatives of this County to enter upon l
�th�e mention operty for inspection purposes
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Perini tee to 1