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WORKERS'COMPENSATION DECLARATION I 78-808 ioiat A 1:.PP1 IC ATIO,N .FOR ELECTRICAL PERMIT
I hereby affirm that hav
I.. e a certificate CE-aoeG /y i+/ 1 of consent to self insure,'
or a certificate of Workers' Compenslition Insurrenca,or a certified, COUNTY OF LOS ANGELES BUILDING AND SAFETY-
copy thereof(Sea 3800,Lab.C.)
Policy No. Company FOR APPLICANT TO FILL IN ;.JOB +
he
❑ Certified copy is hereby furnished. ; ADDRESS e/ gZ1vyb SD�New Residential Bldgs.&Pools EACH NO. FEE.
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Certified copy is filed with the county building InspectionI 1 &2-Family,.Sq.Ft. /.05 $ — $ 1 F�?
department. Multi-family Sq.Ft. — NEAREST
Residential Swimming Pools :CROSS.ST. 60 d.
Date Applicant OWNER OR
•� �
CERTIFICATE OF EXEMPTION FROM WORKERS' MAL
Outlets:Red—LiFIRM-NAME
Light—Sw..—
COMPENSATION INSURANCE I ADDRESS
(This section need not be completed If the work Involved by the First 20
Total.No. Additional CITY Tel.No..
permit Is for one hundred dollars($:100)or less.) �PLAN CHECK
I certify that in the performance of the.work for which_this permit .�
is issued, I shall not employ a ,APPLICANT
p y ny person in any manner so as to ,
become subject'to the Workers"Compensation.Laws. Lighting.Fixtures First 20 I ADDRESS
'/^� /r�� ,/� Additional
Date C ��f �0 Applicant. a it—W a f cc'' Total,No. 'CITY Tel.-No.
NOTICE TO APPLICANT. If, after 'making this Certificate Fixed Appliances Not Over 1 HP' PERMIT /�++
Exemption,you should become subject.to the Workers'Compensation Range_ Heater_ D.W. _' APPLICANT L:7 ( -Q e
provisions of the Labor Code,you must forthwith comply with suclj Oven Dryer_ W.M._ ADDRESS. 470
provisions or this permit-shall be deemed revoked. Top. FAU _ W:H.
'CIT - b-% Tel.No... .
r
LICENSED CONTRACTORS DECLARATION I Hood _ Fan _ Other_ vn O C I� W1
I hereby affirm that I am licensed under,provisions of Chapter 9 :'LICENSE OR.
Disp. — Room Air Cond. '-*�/ a � Class.
(commencing with Section 7000).of Division 3 of the Business and ,REG.NUMBER . —/p �!� �
Professions Code,and my license is in full force and.effect. II. power Apparatus&'Large Appliances DISTRICT NO. PRO C S D BY
�+,f I Size&Type HP;KW,KVA,or KVAR
License Number .e �L.Lia..Class, � I Up to 1 Incl: FINAL
G '•Fi>e c I Over 1 to 10 Incl. DATE
Contractor Date d. ' ' VALIDATION. p
Over 10 to 50 Incl.
El am exempt under Sec. Over 50 to 100 Ind. FINAL
Over 100 BY LrfA OW,.
B.&P.C:for this reason y
Cy ateServices,Swbd.,MCC&Panelboards ® Z_
:- `: 0-200 Amp.Under 600 V
Signature '� 201 : 1000 Amp.Under 600 V
Over 1000 Amp.or Over 600 V
❑ Exemption for geg.Maint.Elect. l ,
SINGLE FAMILY 'I Temp..Power Pole&Appurtenances ";
HOME.OWNER-BUILDER DECLARATION Sign with One Branch Circuit r i
'I hereby affirm that I.ani•exempt from the Contractor's License Law f. s'
for the,following,reason(Section 7031:5,Business and Professions Additional Sign Branch.Circuits ACCT F
Code): i— 115.50{� C[[
+''-:707 .115.50
�r Misc.,Conduits&Conductors
❑ I,as owner of the property,will do the work and the structure 1 ITEMS
is not intended or offered for sale (Section 7044;.Business Other(See Complete Fee Schedule) _
and Professions Code). ® TOTAL 1105 m 50
CONSTRUCTION LENDING AGENCY i CHECK 115.511
1 hereby•affirm.. that there.is a construction..lending agency for the r
performance of the work for which this permit is issued(Sec.3097, .PERMIT FEE (Sub-Total) CH(�tHIGE ;117"
Civ.'C.). �� -•
PLAN CHECKING FEE
Lender's Name / _000C 4/°!I
PERMIT ISSUING FEE,
Lenders AddressEE FEE es �)f'i11}�'19
f
l certify that] have read.this.application and state that the above T - � . .,'
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
property for inspection purposes.
SEE REVERSE FOR EXPLANATORY LANGUAGE
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Signature.of Permittee Date
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