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WORKERS'COMPENSATION DECLARATION 20-0019 DPW 3/87 ������n��0� �O�y �p ������n p���0�
I hereby affirm that I have a certificate of consent to self ,CE° A R L5 A O
insure, o1a•certificate of Workers' Compensation Insurance, COUNTY OF LOS ANGELES DEPT. OF PUBLIC WORKS
or a certified copy thereof (Sec 3800, Lab C )
Policy No Company FOR APPLICANT TO FILL IN JOB
❑Certified cop is hereby furnished New Residential Bidgs & Pools EACH NO FEE ADDRESS
❑Certified copy i filed with the county budding inspec- ,1 & 2-Family, Scl Ft $ _ $ LOCALITY r
tion department Multi-family Scl Ft NEAREST
M
Residential Swimming Pools WNECROSS ST / 17 Ac/�
Date Applicant
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets Rec LightSw o MAIL
COMPENSATION INSURANCE OQ ADDRESS J
First 20
(This section need not be completed if The work involved by Total No Additional CITY ��� e No������,
the permit is For one hundred dollars ($100)or less.) PLAN CHECK
I 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 Workers'Compens tion Laws Lighting Fixtures First 20 ADDRESS
Additional
Total No CITY Tel No
Date a Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO AP LICANT If, after making this Certificate of
APPLICATION
Exemption, you should become subject to the Workers' Range— Heater—DW r ?et
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 _L—W H —
deemed revoked Hood — Fan —Other— / CITY 9�� Tel No 4
LICENSED CONTRACTORS DECLARATION Disp — Room Air Cond / C� LICENSE OR
I hereby affirm that I am licensed under provisions of Chapter 9 REG NUMBER 3 Clas
(commencing with Section 7000)of Division 3 of the Business Power Apparatus& Large Appliances DISTRICT NO PROCESSED BY d
and Professions Code,and my license is in full force and effect
Size &Type HP, KW, KVA, or KVAR �Z� 0
License Number�(G31SJ� Lic Class Up to 1 Incl FINAL
Z Over 1 to 10 Incl DATE VALIDATION 0
Contra I Date Over 10 to 50 Incl O
❑ " AL
m exempt unde ec Over 50 to 100 Inc BY W
Over 100 �
B 8P C for this reason
Services, Swbd , MCC& Panelboords D �
Date Z
0-200 Amp Under 600V / J1 �
Signature 201 - 1000 Amp Under 600 V
❑ Exemption for Reg Maint Elect Over 1000 Amp or Over 600 V�
SINGLE FAMILY Temp Power Pole &Appurtenances / y
HOME OWNER-BUILDER DECLARATION t?s. °a
I hereby affirm that I am exempt from the Contractor's License Sign with One Branch Circuit Additional Sign Branch Circuits t7
20.70
Law for the following reason (Section 7031 5, Business and g •7
Professions Code) t t
1 �r`{
Misc Conduits&Conductors
❑ I, as owner of the property, will do the work and the - —a �
structure is not intended or offered for sale(Section 7044, Other (See Complete Fee Schedule)— t TOTAL(AL 20 - 70
Business and Professions Code) D CHECK 2,Ch7i 1
CONSTRUCTION LENDING AGENCY
'I hereby affirm that there is a construction lending agency for `•HAf�K °I N
the performance of the work for which this permit is issued PERMIT FEE (Sub-Total)
(Sec 3097, Civ C )
PLAN CHECKING FEE i li_i�(_f i{l l�i 1 i;'•' IrF%'+1_s'
Lender's Name
PERMIT ISSUING FEE J3 Q �50S, i hM
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
abo a-men i reed o erty for inspection purposes
I ' SEE REVERSE FOR EXPLANATORY LANGUAGE
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gnature of Permittee D e