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"'WORKER'S COMPENSATION DECLARATION 20-0019 DPW 8/89 APPLICATION ®® ������OLa�L ��R�O�
I hereby affirm that I,have a certificate of consent to self insure, 9-i
or a certificate of Worker's Compensation Insurance, or a certified COUNTY OF LOS ANGELES DEPT.OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Sec.3800 Lab.C.)
Policy No. S� Company ���,D' / —/`e'"/ FOR APPLICANT TO FILL IN JOB l LU(ySL L
ADDRESS
Certified copy is hereby furnished. New Residential Bldgs.&P I EACH NO. FEE LOCALITY
I� 1&2-Family,Sq.Ft. _ $ C
Y Certified copy is filed with the county building inspection NEAREST � n
department. Multi-family Sq.Ft. CROSS ST.
Date Z Applicant Residential Swimming Pools ASSESSOR
1.
MAP BOOK PAGE PARCEL
CERTIFICATE OF EXEMPTION FROM ORKE 0�0Outlets:Rec._Light Sw. OWN NAMFIRME
E.
COMPENSATION INSURANCE First 20
(This section need not be completed If the work Involved by the MAIL,
permit is for one hundred dollars($100)or less.) Total No. Additional ADDRESS
I certify that in the performance of the work for which this permit CITY Tel.No.
Is Issued, I shall not employ any person in any manner so as to PLAN CHECK
become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 APPLICANT
Total No. Additional
_ ADDRESS
Date Applicant 15 OR 20A,120V BRANCH CIRCUITS
NOTICE TO APPLICANT: If, after making this Certificate of CITY Tel.No.
Exemption,you should become subject to the Workers'Compensation 1 TO 10 INCLUSIVE EACH .---
provisions of the Labor Code,you must forthwith comply with such 11 TO 40 INCLUSIVE EACH APPLICANT L� -'Z(�
provisions or this permit shall be deemed revoked. 41 OR MORE BRANCH CIRCUITS EACH
Le-
LICENSED CONTRACTORS DECLARATION ADDRESS 3"ZL''�`l C f3 J d
I.hereby affirm that I am licensed under provisions of Chapter 9 15 OR 20A,208V TO 277V LIGHTING EACH O
(commencing with Section 7000)of Division 3 of the Business and CITY CTd.No. 0331 J ()
Professions Code,and my license is in full force and effect. RESIDENTIAL APPLIANCES UP TO SHP LICENSE OR
�Z, Power Apparatus&.Large Appliances REO.NUMBER yy Class. C 7� O
License Number6 ` 3��V Lic.Class C '� Size&Type HP,KW,KVA,or KVAR DISTRICT NO.I. / PROCESSED BY U
/S/�.�/`f L- / . _ Up to 3 Incl 0 l/ �s 0-
Contras GL Date l9 Over 3 to 10 Incl. FINAL �
❑ Over 10 to 50 Incl. DATEZ
I am exempt under Sec. ` Over 50 to 100 Incl., VALIDATION
B.&P.C.for this reason _
Over 100 BYAL
Services,Swbd.,MCC&Panelboards
Dale.' 0-200 Amp.Under 600 V
Signature 201-1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V
❑ Exemption for Reg.Maint.Elect.
SINGLE FAMILY Temp.Power Pole&Appurtenances
HOME OWNER-BUILDER DECLARATION Sign with One Branch Circuit '
I hereby affirm that I am exempt from the Contractor's License Law - -
for the following reason(Section 7031.5, Business and Professions Additional Sign Branch Circuits _ �•' _ •'
Code):
❑ .. ..;.:fig_
I,as owner of the property,will do the work and the structure Misc.Conduits&Conductors
Is not intended or offered for sale(Section 7044, Business Other(See Complete Fee Schedule) "!°-• ]= '
and Professions Cade).
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.3087,
P P ( PERMIT FEE (Sub-Total) � 3
Civ.C.)
PLAN CHECKING FEE
Lender's Name
PERMIT ISSUING FEE
Lender's Address
I certify that) have read this application and state that the above TOTAL FEE F�
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-mentioned
propert or inspection purposes SEE REVERSE FOR EXPLANATORY LANGUAGE
SIGNATURE OF APPLICAWWR AGENT DATE '