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i� I`h70RKERS'COMPENSATION DECLARATION 76-663 10/81 APPLICATION F®® ELECTRICAL
LEC RICA ® PERMIT
P"d.
r'hereby Vfirm that I have a certificate of consent to self CE-806G I!"tI Ceb O� IS t5 L5 1� /�B6 C]` ®®f1�W s+�
insure, or a certificate of Workers'Compensation Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY C 6a 6
or a certified copy thereof(Sec. 3800, Lab. C.)
Policy No. 5501 15 Company STATE FUM J FOR APPLICANT TO FILL IN ApDRESS 97 i�J QR LN.Certified copy is hereby furnished. New Residential Bldgs. &Pools EACH NO. FEE
Certified copy is filed with the county building inspec- y, q. 1630 $.038 — $ LOCALITY CITY
1 8 2-Family, S Ft. 1
WE—
tion department. Multi-family Sq. Ft. — NEAREST
r CROSS ST.
Residential Swimming Pools +� I` OWNER OR
Date 11-24-86 Applicant, v- _sT11��
FIRM NAME
CERTIFICATE OF EXEMPTION FROM WORKERS' Outlets: Rec Light Sw._ MAIL
COMPENSATION INSURANCE First 20 ADDRESS 2035 NRYWE
(This section need not be completed if the work Involved by Total No. Additional CITY VIA 91706 Tel. No.359-3211
the permit Is for one hundred dollars($100)or less.)
I certifythat in the performance of the work for which this PLAN CHECK
P APPLICANT
permit is issued, I shall not employ any person in any manner
so as to become subject to the Workers'Compensation Laws. Lighting Fixtures First 20 ADDRESS
Total No. Additional
CITY Tel. No.
Date Applicant Fixed Appliances Not Over 1 HP PERMIT
NOTICE TO APPLICANT:. If, after making this Certificate of APPLICANT aTI�RYr$ Ef.F><"7'RTIC 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 14923 '1$I:,1113. AVE,
with comply with such provisions or this permit shall be Top _ FAU —W.H. — 597-4741
deemed revoked. CITY � Tel. No.
LICENSED CONTRACTORS DECLARATION Hood _ Fan _Other_ - -
LICENSE OR
Disp. _ Room Air Cond. Class.C-1®
I hereby affirm that I am licensed under provisions of Chapter 9 � REG. NUMBER 259475
(commencing with Section 7000)of Division 3 of the Business DISTRICT NO. PR SE BY
and Professions Code,and my license is in full force and effect. Power Apparatus&Large Appliances
Size&Type HP, KW, KVA, or KVAR-
License Number Lic. Class C 10 Up to 1 Incl. FINAL LIZ
I Over 1 to 10 Incl. DATE r ALIDATIORI
ContractorsnTCDate 11-24-86 I
❑ Over 10 to 50 Incl.
1INr/
I am exempt under Sec. Over 50 to 100 Inc. BY A 6 9 0,5 A L!J
a
B.&P.C. for this reason Over 100 # a o a o 02
Services, Swbd., MCC&Ponelboards
Date: 0 -200 Amp. Under 600 V 1 010'7 2 4 4
Signature 201 - 1000 Amp. Under 600 V o 0 o7244'0 .
❑ Exemption for Reg. Maint. Elect. Over 1000 Amp. or Over 600 V
0423=87
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 Additional Sign Branch Circuits
Law for the following reason (Section 7031.5, Business and
Professions Code):
❑ I, as owner of the property, will do the work and the Misc. Conduits&Conductors
structure is not intended or offered for sale (Section Other(See Complete Fee Schedule)_
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. 3097, Civ. C.).
PLAN CHECKING FEE
Lender's Name PERMIT ISSUING FEE 101.50
Lender's Address ,
I certify that I have read this application and state that the TOTAL FEE 72.44
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
t bows- ntio d pr rty fo nspectio purpose . SEE REVERSE FOR EXPLANATORY LANGUAGE
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