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✓ '' RK§RS'COMPENSATION DECLARATION 76A663 10/81 APPLICATION FOR ELECTRICAL PERMIT
1-thereby affirm that I have a certificate of consent to self CE-&MG {�
insure;or a ceyificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
aIu1
or 'ce�tified copy thereof(Sec. 3800, Lab. C. i
Policy No.550115 Company- SATE 17EM FOR APPLICANT TO FILL IN JOB
Certified copy y is hereby furnished. New Residential Bldgs. 8 Pools EACH NO. FEE ADDRESS 970.9. ]u( ' WY
ER Certified copy is filed with the county building inspec- 1 &2-Family, Sq. Ft:1942 $ — $ LOCALITY Cly
tion department. Multi-family Sq. Ft. — NEAREST
12-1-86JERRY"S ELECT-moi� .Residential Swimming Pools 'CROSS ST.
Date Applicant OWNER OR
EIAPr�1T
CERTIFICATE OF EXEMPTION FROM WORKERS' IL
Outlets: Rec Light Sw._
FIRM.NAME (]W$11.5
COMPENSATION INSURANCE � DDRESS 2035 MYRTLE( P b
This section need.not be completed IF the work Involved First 20
y l No
Total . Additional CITY NIA Te(. NO.359-3211
the permit Is for one hundred dollars($100)or less.) ToPIAN 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'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
Date- Applicant CITY Tel. No.
Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO. APPLICANT: If, after making this Certificate of APPLICANT JEMffvS ELECTRIC, 1W.
Exemption, you should become subject 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:— 3876 DIONEUM ]RD.
deemed revoked. Hood — Fan _Other— CITY BN[Wf71i PARK Tel. No..338-2558 �
LICENSED CONTRACTORS DECLARATION LICENSE OR
Dis _ Room Air Cond. —
I hereby affirm that I am licensed under provisions of Cha}�ter 9 p' REG.NUMBER 259475 ClassC 70
(commencing with Section 7000)of Division 3 of the Business S D power Apparatus 8 Large Appliances DISTRICT N PROCESY d
and Professions Code,and my license is in full force and effect. ,) 0
Size&Type HP, KW, KVA, or KVAR' c (/ 0
License NumbeerDp259475�y+ Lie. CI'ass C-10 Up to 1 Incl. FINAL,-,
.11 5 IS 1?aGGll.. 12-1-86 Over 1 to 10 Incl. DATE ,roY VALID N
Contractor i to Over 10 to 50 Incl. Fl L W
❑ I am exempt under Sec. Over 50 to 100 Inc.
Over 100
B.&P.C. for this reason
Z
Services, Swbd., MCC&Panelboards
Date: 0 -200 Amp. Under 600 V
Signature 201 - 1000 Amp. Under 600V
❑ Over 1000 Amp. or Over 600 V
Exemption for Reg. Maint. Elect.
SINGLE FAMILY- Tem Power Pole&Appurtenances c
HOME OWNER-BUILDER DECLARATION p• pP # 0 0 0
Sign with One Branch Circuit
I hereby affirm that I am exempt from the Contractor's License ( o.- 84.29
'
Law for the following reason (Section.7031.5, Business and Additional Sign Branch Circuits
Professions Code): ) 0 008k-29- 5
❑ Misc. Conduits&Conductors
I, as owner of the property, will do the work and the �.
structure is not intended or offered for sale (Section Other(See.Complete Fee Schedule)_ ® 12 2 4 B 6
7044, Business and Professions Code).
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 (Sub-Total)
(Sec. 373 7
097, Civ. C.).
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE i .5
Lender's Address
I certify that I have read this application and state that the TOTAL FEE 84.2
above information it correct.]agree.to comply with all County
ordinances.and S e laws regulating Electrical wiring, and
hereby)authorize a'resent'atives of this County to enter upon
th ve-me ti n d property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
Signature of Permittee Date