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WORKERS'COMPENSATION DECLARATION10E-BOBG78-883 10/81 APPLICATION FOR ELECTRICAL PERMIT
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I het'eby.—affirm that I have a certificate of consent to self insure,
or a certificate of Workers'Compensation Insurance,or a certified # COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof(Sec.3800,Lab.C.) f
Policy No.1,0 0Sl(s7 Company-S --ta FOR APPLICANT TO FILL IN JOB
❑ 3
Certified copy is hereby furnished. New Residential Bldgs.&Pools EACH NO. FEE ADDRESS CY1
—
Certified copy is filed with the county building Inspection 1 &2-Family,Sq.Ft. $ $ LOCALITY C1
NEAREST
department. Multi-family Sq.Ft. CROSS ST.
Date Applicant Residential Swimming Pools OWNER OR ,
FIRM NAME J
CERTIFICATE OF EXEMPTION FROM.W RKERS' MAIL
COMPENSATION INSURANCE Outlets Rec—Light—Sw.— ADDRESS tNC K
(This section need not be completed if the work involved by the First 20
CITY Tel..No.
permit is for-one hundred dollars($100)or less.) Total No. Additional Q'w►. C,, "9-2
I certify that in the performance of the work for which this permit PLAN CHECK
Is issued, I shall not employ any person in any manner so as to APPLICANT
become subject to the Workers'Compensation Laws. Lighting Fixtures f'First 20 ADDRESS
Additional
Total No. CITY Tel.No.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Fixed Appliances Not Over.1 HP ' .PERMIT `
Exemption.,you-should become subject to the Workers'Compensation Range_ Heater D.W. _ APPLICANT V LK , 'a
provisions of the Labor Code,you must forthwith comply with such Oven_ Dryer_ W.M._ ADDRESSLtACVFC
provisions or this permit shall be deemed revoked. Top — FAU _ W.H. _
LICENSED.CONTRACTORS DECLARATION Hood _ Fan _ Other_ CITY -t- Tel.N0.LT Lig,-I
I hereby affirm that I am licensed under provisions of Chapter 9 Disp. — Room Air Cond. LICENSE OR Class.
(commencing with Section 7000)of Division 3 of the Business and REG.NUMBER.
Professions Code,and my license is in full force and effect.' Power Apparatus&Large Appliances DISTRICT NO. PROCESS Y
- !:
Size&Type HP,KW,KVA,t or KVAR (/ ,
License Number Lid.Class Up to 1 Incl. FINAL
Contractor Date Over 1 to 10 Inc[. , DATE VALIDATION 0
❑ Over 10 to 50 Incl.
FINAL .
I am exempt under Sec. Over 50 to 100 Inc. BY W
B.&P.C.for this reason. Over 100 N
Services,Swbd.,MCC&Panelboards
Date. 0-200 Amp.Under. 600.V
Signature 201 - 1000 Amp.Under 600 V
E] Exemption
1000 Amp.or Over 600 V
Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances 3307 31.01;
HOME OWNER-BUILDER'DECLARATION Sign with One Branch Circuit
I hereby..affirm that I am exempt from the Contractor's License Law Additional Sign Branch Circuits 1 ITE
for the following reason(Section 7031.5,Business and Professions
Code):
Misc.Conduits&Conductors TOTAL 3:.®00
ElI .,
I,as owner of the property,will do the work and the structure�(,{ ;r 1,i,;l�
is not Intended or offered for•sale (Section 7044, Business Other(See Complete Fee Schedule) —
and Professions Code). ' , CHANGE .011
I
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(Sec.3097, PERMIT FEE (Sub-Total) { 0000-0001 6/ 6/90
Civ.C.). I
PLAN CHECKING FEE 1120 1 AM 7-44
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that I have read this application and state that the above TOTAL FEE. '(
nformation is correct,I agree to comply with all County ordinances
nd State laws regulating Electrical wiring, and hereby authorize I
presentatives of this County to enter upon the above-mentioned
roperty for inspection pur sea.
� � ! SEE REVERSE FOR EXPLANATORY LANGUAGE
w i
ign ture of Perfniffee DateI