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WORKERS COMPENSATION DECLARATION 768663 I 01 I w APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of copse it'to self - CE e06G r -
insure or a certificate of Workers Compensation Insurance COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec 3800 Lab C ) ( , (
Policy No Company I FOR APPLICANT TO FILL IN JOB
ADDRESS /
Certified copy is hereby furnished New Residential Bldgs & Pools EACH NO FEE ` c
Certified copy is filed with the county building mspec 1 & 2 Family Sq F11 $ — $ LOCALITY
Ad
tion departmentMulti family Sq Ft CROSS NEARESTT
' Residential Swimming Pools OWNER OR t
Date "` Applicant4-Z_ZLa�l
1 FIRM NAME G
T CERTIFICATE OF EXEMPTION FROM WORKERS
Outlets Rec Light Sw
COMPENSATION INSURANCE First 20 2Q .� ADDRESS
(This section need not be completed if the work involved by Total No �- CITY Tel No
the permit is for one hundred dollars ($100) or less ) Additional r
I certifythat in the performance of the work for which this PLAN HECK
P � -y_ APPLICANT
permit is issued I shall not employ any person in any manner
so as to become subject to the Workers Compensatio Laws Lighting Fixtures First 20 ADDRESS
t t Additional
//�q � Total No CITY Tel No
Date d- Applicant xed Appliances Not Over 1 HP PERMIT `
NOTICE TO APPLICANT If after making this Certificate of
Exemption you should become subject to the Workers Range_ Heater_D W
Compensation provisions of the Labor Code you must forth Oven _ DryerW M ADDRESS
with comply with such provisions or this permit shall be Top I _ FAU —W H a JCITY Tel No
y
deemed revoked Hood Fan _ Other—
LICENSED CONTRACTORS DECLARATION
J Disp Room Air Cond REGNNUMBER + Class
I hereby affirm that I am licensed under provisions of Chapter 9 -
(commencing with Section 7000) of Division 3 of the Business DISTRICT>Q PROD BY
and Professions Code and m license is in full force and effect Power Apparatus& Large Appliances 911.
>_y r Size &Type HP KW KVA or KVAR L D Q
License Number Lrc Class Up to 1 Incl _ FINAL V
1 Over 1 to 10 Incl DATE VALI ION oC
Contractor Date Over 10 to 50 Incl 4 O
❑ FINAL e U
I am exempt under Sec Over 50 to 100 Inc BY / W
Over 100CL
�,1 1 1 4 H
B &P C for this reason -
Services Swbd MCC & Ponelboards # o e o 0 o Z
Date 0 200 Amp Under 600 V ® e - 3525
Signature J 201 1000 Amp Under 600V o e e 3.5 2 5 5
1 a ' Over 1 000Amp or Over 600 V
Exemption for Reg Maint Eject I,, t
T1 '
I SINGLE FAMILY Temp Power Pole &Appurtenances
I HOME OWNER BUILDER DECLARATION
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor s License Additional Sign Branch Circuits ,
Law for the following reason (Section 7031 5 Business and
Professions Code) (r 1 '
I as owner of the property will do the work and the Misc Conduits& Conductors „
structure is not intended or offered for sale (Section Other (See Complete Fee Schedule)_
7044 Business and Professions Code) 1 ® s
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 f (Sub Total)
(Sec 30971 Civ C ) t
w
PLAN CHECKING FEE
Lender s Name
r � PERMIT ISSUING FEE i 5 + r _
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 / I
hereby authorize representatives of this County to enter upon
the above mentioned property for inspectsQn purposes 1
e^
� SEE REVERSE FOR EXPLANATORY LANGUAGE
11.Ve � � `
Signa e o Permittee Date
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