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WORKERS'COMPENSATION DECLARATION .r 76A883 10/81 APPLICATION FOR ELECTRICAL PERMIT .
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I hereby affirm that i have a certificate of conser{j to sc4f•)psure, '93'808G
or a certificate of Workers' Compensation,,lnsurance, or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY
copy thereof.(See.3800,Lab.C.).
Policy No. Company FOR APPLICANT TO FILL IN JOB //� pDe�`�� Q ,
❑ Certified copy is hereby furnished. EACH NO. FEE ADDRESS C7( /L J '7i� k7
New Residential Bldgs.&Pools
LOCALITY
E] Certified copy is filed with the county building Inspection Jr
1 &2-Family,Sq.Ft. $ _ $
department. Multi-family Sq.Ft. 62:82rs NEAREST •7� t d
�^ CROSS ST.4aPaAVL
Date Applicant Residential:Swimming Pools OWNER OR
FIRM NAMETA A 7e
! z 4z
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets:Rec—Light_Sw.— MAIL f
COMPENSATION INSURANCE t ADDRESSp ..
(This section need not be completed If the work Involved by the First 20
permit is for one hundred dollars($100)or less.) Total No. Additional CITY AJ Tel.No. fir*
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 First 20 ADDRESS
Additional
Total No. CITY Tel.No.
Date V Applicant Fixed Appliances Not Over 1 HP
'
NOTICIE TO APPLICANT: If, after makin this Certificate of PERMIT
{ Exemption,you should become subject to the Workers'Compensation
Flange_ Heater D.W. _ APPUCA
provisions of the Labor Code,you must forthwith comply with such Oven Dryer_ W.M._ ADDRESSS
provisions or this permit'shall be deemed revoked. Top FAU _ W.H.
I LICENSED CONTRACTORS DECLARATION Hood — Fan _ Other_ CITY ,�t� •� Tel.N. j.7.
I hereby affirm. that I am licensed under provisions of Chapter 9 `Disp. — Room A'ir Cond. LICENSE OR 6 Clasa'Gr��O
(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. PROCEVRED BY
�-�j� /, / Size&Type.HP,KW,'KVA,or KVAR 0
License Numbers/_747 f�o Lic.Class e—Z C7 Up to 1.Incl. I FINAL �G 0
I Over 1 to 10 Incl. DATE /
_ ` VALIDATION
i Contracto Date a Over 10 to 50 Incl. FINAL O
❑ 1 am exempt under Sec./N Over 50 to 100 Inc. gy �`/ y✓Jj� 15
LLI
BAP.C.for this reason i Over 100 " /� N
yServices,Swbd.,MCC&Panelboards
i Date: 0-200 Amp.Under 600 V Me%
Signature 201.- 1000 Amp..Under 600 V I
Over 1000 Amp.or Over 600 V
ElExemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
{ HOME OWNER-BUILDER DECLARATION 1Sign with One Branch Circuit
1 I hereby affirm that I am exempt from the Contractor's:License Law I Additional Sign Branch Circuits � �oa
for the following reason(Section 7031.5,Business and Professions
Code): j 3307 244 o 6Q
j Misc.Conduits&Cdnductors❑ 1 ITEMS I,as owner of the property,will do the work and the structure I
is not intended or offered for sale (Section 7044, Business Other(See Complete Fee Schedule) _
1 and Professions Code). I ! I pop. TOTAL 244-60
CONSTRUCTION LENDING AGENCY CHECK 24406[)
I hereby affirm that there is a construction lending agency for the
performance of the work for which this permit is issued(Sec.3097, i PERMIT FEE (Sub Total) . CHANGE .00
Civ..C.).
PLAN CHECKING FEE
Lender's Name 0000_0001 7/17/911
PERMIT ISSUING FEE I
Lender's Address/ 0 V �� �,�°� - �•� 1853 1 AM 10:34
I certify that.I have read,this application and state that the above TOTAL FEE
information is correct.Iy ordinances
agree to comply with all Court ;
I and State laws regulating Electrical wiring, and hereby authorize
representatives of this County to enter upon the above-mentioned
property for inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
igna of Pe .ittee Date
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