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WORKER$'COMPENSATION DECLARATION 3
E-130
CE�060 (2-80) APPLICATIONFOR ELECTRICAL PERMIT
'
I hereby affirm that I 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.)
FOR APPLICANT TO FILL IN SOB
Policy No. Company EACH NO. FEE ADDRESS (o
New Residential Bldgs.&Pools
Certified copy is hereby furnished. 1&2-Famlly,Sq:Ft. ; — $ LOCALITY
Certified copy 4 flied with the county building inspection Multi-itimlly Sq. Ft. CROSS 8T `.
depprtment. Residential Swimming Pools
OWNER OR
IRM NAME
Date Applicant Outlets: Rec,11- Sw. AMAIL
DDRESS fs
rst 20
CERTIFICATE OF'EXEMPTION FROM WORKERS' Total NoAdditional CITY OL C C'rTyr.4 No.�
COMPENSATION INSURANCE PLAN CHECK
(This sactbn need not be completed if the, work larolred PPLICANT
by the permit L for one hundred dollars ($100) or len.) Lighting Fixtures First 20 ADDRESS
Addltlonal
I certify that.in the performance of the work for which this Tote) No. CITY Tel No. O
Fixed Appllen Not Over 1 HP U
permit Le,.coissued, I shall not employ any p�xto❑ In any manna PERMIT W
so as to become subject to the Worken' Compensation Laws. Range_ Hester D.W. _ PP [CANT a
Oven _ Dryer_W.M._ ADDRESS
Date-7' 'AppllcmtzxNA `40 Top _ FAU W.H.
Hood _ Fen _Other— CITY ktz—
al No.
NOTICE TO APPLICANT: If, after making this Certificate of - Dlsp. _ Room Air CdndLLCENSE OR
Exemption, you should become subject to the. Workers' REG,NUMBER Clean
Compensation provisions of the Labor Code, you must forth- Power Apparms& Large Appliances DISTRICT NO. PROCE ED BY
with comply with such provisions or this permit shall be Sim W
&Type HP,K , KVA,or KVA
deemed revoked Up to 1 Incl.
Over 1 to 10 Inc]. FINAL
DATE
LICENSED CONTRACTORS DECLARATION Over 10 to 60 Incl. VALIDATION
I hereby affirm that I am Licensed under provisions of Chapter Over 50 to 100 Inc. FINA
BY
9 (commencing with Section 7000) of Division 3 of the Busl- —T— Ovbr 100 t
near and Professions Code, and my license Is in full force and
effect. SArvices )
0-200 Amp,Under 800 V
License Number Llc.Class 201-1000 Amp.Under 600.V
Contractor_ Date Oyer 1000 Amp.or Over 600 V
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I hereby affirm that I am exempt from the Contractor's Sign wlth Ona Branch Circuit
li Llcanso'Law for the following reason (Section 7031.5, Bust- Additional Sign Branch Circuits 4 039 A
neu and Professions Code): ,o,e c a e 2
Misc.Conduits&Conductor
1, as owner of the property, will do the work and the . Other(See Complete Fee Schedule)— 2 o e 4500
structure Is. not intended or offered for sale (Section r
7044, Business and Professions Code). u lL( 5 0 0
CONSTRUCTION LENDING A0ENCY
I hereby afftrm that there is a construction lending agency
0 7^8 4
for the performance of the work for which this p6rmit is Q
Issued(Sec. 3097,Civ,C.). PERMIT FEE (Sub�Total)
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE
I certify that I have read this application and state that-the TOTAL FEE
above Information 14 correct.I agree to comply with all County
ordinances and Sp laws regulating Electrical wiring, and
hereby ■ horl" r resentetives of this County to enter ppon
the a men pro rpwtion purposes. SEE'REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Data