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-- WORftFS'COMPENSATION DECLARATION 76A663 10/8I
%l hereE/-affirm that I have a certificate of consent to self CE-806G APPLICATION C® m ELECTRICAL PGDHI4
insure, orad certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
or a certified copy thereof (Sec. 3800, Lab. C.)
Policy No__�Company FOR APPLICANT TO FILL IN JOB
Certified copy isS'D,hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS - e4rl Lint
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CertifiedKo{(yr is filed with the count building inspec- 18 2-Family, Sq. Ft. $ _ $ LOCALITY '' .P zL�Q— C �.•1 L�
tion department. Multi-family Sq. Ft. CROSS NEAREST 9(s./Jl.f713'I` si�•N SIr} �' /ovL�L.0 C! (V
Date Applicant Residential Swimming Pools`y\ ` .OWNER OR
- FIRM NAME Su,1 � l_XXL
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Reco Light Sw$ vs 'MAIDDRESS 5� FL.L-IL A/)
COMPENSATION INSURANCE . g
(This section need not be completed if the work Involved by 3 . First 20
the permit is for one hundred dollars($100)or less.) Total No._
Additional yJ CITY��a(��L�. C' '�-� Tel. No. �•b_�S
PLA
I certify that in the performance of the work for which this q PLICANTK
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Comp w'on Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional CITY Tel. No.
Date T �—�T If, ant Fixed Appliances Not Over 1 HP PERMIT
NOTICE n, APPLICANT: If, aft 'ma jec this Certificate of APPLICANT
Exemption, you should become bject to the Workers' Range_ Heater_D.W.. —
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. Hood Fan _Other_' CITY Tel. No.
_
LICENSED CONTRACTORS DECLARATION 5 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 8 Large Appliances DISTRICT NO. PRO D BY y
and Professions Code,and my license is in full force and effect. f �j 06
Size 8 Type HP, KW, KVA, or KVARO
License Number LIc. Class Up to 1 Incl. FINAL V
Over,l to 10 Incl. DATE 3-GQ VALIDATION Q
Contractor Date Over 10 to 50 Ind.
❑ FINAL U
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.BP.C. for this reason Over 100 Z
Date: - Services- Swbd., MCC K Ponelboords D
0 -200 Amp, Under 600 V
Signature 201 - 1000 Amp. Under 600 V '
❑ Over 1000 Amp. or Over 600 V '
Exemption for Reg. Moint. Elect.
SINGLE FAMILY Temp. Power Pole 8 Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit o
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
Pro essions Code): $ .(
Misc. Conduits 8 Conductors Xt
I, as owner of the property, will the work and the
structure is not intended or offered for sole (Section Other (See Complete Fee Schedule)_ D
yb7044, Business and Professions Code). -
CONSTRUCTION LENDING AGENCY L9
I hereby affirm that there is a construction lending agency for 2—
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec. 3097, Civ. C.). 0
PLAN CHECKING FEE ,36, e
Lender's Name (�k
PERMIT ISSUING FEE p ,
lender's Address ? p
I certify that 1 have read this application and state that the TOTAL FEE p g Q
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 e abo property for inspection urpos s.
l �y Q SEE REVERSE FOR EXPLANATORY LANGUAGE
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Sign Lure of Permittee Do