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WORKERS'COMPENSATION DECLARATION � 806G,(2.80) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a certificate of consent to selfCOUNTY OF LOS ANGELES BUILDING AND SAFETY
insure,or a certificate of.Workers'Compensation Insurance,or 1
a certified copy thereof.(Sec:.3800,,Lab.C.) • .1
FOR APPLICANT TO FILL IN JOB
Policy No. Company EACH NO. FEE ADDRESS(O �$
New Residential Bldgs.&Pools f
13 Certified copy is hereby furnished. 1 &2-Family,Sq. Ft. $ — $ - LOCALITY
El Certified copy is filed with the count buildin Multi-family Sq.Ft. NEAREST
y g inspection Residential Swimming Pools CROSS ST
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department. OWNER OR
FIRM NAME .
Date Applicant: Outlets: Rec.—Light Sw. MAIL
First 20 ADDRESA0
CERTIFICATE OF EXEMPTION FROM WORKERS' Total No. Additional
COMPENSATION INSURANCE CITY Tel No.
PLAN CHECK �•
(This section need not be completed if the work involved Fixtures First 20 APPLICANT 0O
by the permit is for. one .hundred dollars ($100) or less.) -Lighting ADDRESS
r Total No. Additional
I certify that in the performance of the work for which this Fixed Appliances Not Over.1 HP CITY Tel No.
permit is Issued, I shall not employ any person in any manner PERMIT V
so as to become subject to the Workers'Compensation Laws. Range_Heater D.W. APPLICANT W
• a
Oven Dryer_W.M.— ADDRESS CsL�tIwQ�
Date Applicant Top _FAU, _W.H..—
i Hood _ Fan _Other_ CITY Tel No.
NOTICE'TO APPLICANT: If,after making this Certificate of Disp. _'Room Air Condom LICENSE OR
Exemption, you should become subject to the Workers' REG.NUMBER Class 7
Compensation provisions of the Labor Code, you must forth; ) Power Apparatus&Large Appliances DISTRICT Ny "VALIDA
with comply with such provisions or this permit shall tie �//J
deemed revoked. Size&Type HP,KW,KVA,or KVAR
Up to 1 Incl.
' FINAL LICENSED CONTRACTORS DECLARATION, Over 1 to.10 Incl. DATE / O
Over 10 to 50 Incl. ` a
I hereby affirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. FINAL
9 (commencing with Section 7000)of.Division 3 of the Busi- Over 100
ness and Professions.Code,and my license is in full force and 1
effect. Services
f
License Number. Lic.Class 0-200 Amp.Under 600 V
201-1000 Amp.Under$00 V
Contractor Date Over 1000 Anip.or Over 600 V
I
HOME OWNER-BUILDER DECLARATION Temp.Power Pole&Appurtenances
I. hereby affirm that I am exempt from the Contractor's Sign with One.Branch Circuit
)
License Law for the following reason .(Section 7031.5, Busi= 'I Additional Sign Branch Circuits _
Hess a rofessions Code): 9367
3 6,� .�, A _
Misc.Conduits&Conductors
I, as owner of the property, will do the work and the Other(See Complete Fee Schedule)— # o ° 0 0 0 2
structure is not intended or offered for sale '(Section
7044,Business and Professions Code). 2 ° ° 1 9 5 0
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency
9,50F2cy
for the performance of,the work for which this permit. is o 0 0.
issued(Sec.3097,Civ.C.). PERMIT FEE (Sub-Total)
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee) 01,081-81
Lender's Address I PERMIT ISSUING FEE
I certify that I have read this application and Oate that the I TOTAL FEE f
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 '
the above-men a ed operty for inspection purposes.
�F SEE'REVERSE FOR EXPLANATORY LANGUAGE
i . . — 1
Signature of Permittee Sa Date I