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WORKERS'COMPENSATION DECLARATION 76A663 ,o�a� qpp��CATION FOR ELECTRICAL PERMIT �3�
I hereby affirm Ihat I have a certifimte of mnsenl to self CE-606G {�
insure,o�a cernf�cate o1 Wo�kers Compensaron Insu�ance, COUNTY OF LOS ANGELES BUILDING AND SAFETY ��
or a certitied opy_there ��600,La .C.� �� o ��
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P❑ol�'cy No ►� o pony � FON AMl1GNT T0 Fltl IN JOB �
Certified copy is hereby furnished. New Residenliol Bldgs.8 Paols EACH NO. FEE ADDRESS /IrQ�
� Cerfffied copy is 4iied with the counly boilding insp c- I 8 2-Family,Sq.Ft S = S LOCALITY' �'
NEAREST J
tion dep tmen. /' Multi-fomily Sq.Ft. CRO55 ST.
q..� � � � Residential Swimming Pools OwNER OR
Dale�Appli[ont FIRMNAME YQm (
CERTIFICATE OF EXEMPTION FROM WORKERS' nn,qa
� Outlers:Rec_Lighi_Sw._ r
COMPENSATION INSURANCE ADDRESS ' �.1 R
(Thfa a�cfien�Nd�ot b�tompl�tad if fh�work Involv�d by Firsl 20
. th�p�rmit is for ono hu�dr�d dellan(SI00)or bss.) To�al No. Addirional CITY �Tel.N
I certity Ihot in Ihe periormance of fhe work for which this � � PwN cr+ecc
permil is issued,I sholl not employ ony person in ony manner �- . - �� APP�ICANT
so as to become subjett fo�he Workers'Compensotion laws. Li9hting Fixtures First 20 ADDRE55
Total No. Additional
CITY Tel.No.
Dat<_ npplicaN Fized Appliances Not Over 1 HP PERMIT
Nr`:TO APPLICANT: If, after making Ihis Cerrificote of ' qPppCANT' {
� Ez. .tion, yo� should become subject to �he Workers' Range_Heater_D.W._
' Compensa�ion provisions of the labor Code,you must forih- Oven _Dryer _W.M.— ADDRESS
� with comply w'Ih such provisions or this permit shall be 7op _FAU —W.H.— 7/
' deemad revoked. Hood _Fan _Olher_ CITY �r Tel.N
� LICENSED CONiRACTORS DECLARATION uCENg pR
' D�sp. _Room Air Cond. — Closs.
I hereby oHirm that I om licensed under provitions of Chopter 9 REG.NUMBER (� ��
, (commencing with Section 7000)of Division 3 of Ihe Business power Apporotus 8 large Applionces � �ISTRICT NO. PROCESSED BY d'
� ond Professions Code,pnd my license is in full forte and eifect. . j p
�/�V+ �I/„ Size B Type HP,KW,KVA,or KVAR � /� U
. license Numbery' � �� lia Closs� � UP�a����� FINAL �
� Con�roctor r� u I � Dote -`��tS Over 1 to 10 Ind. DATE � VALIDATtON U
, ❑ Over 10 to 50 IncL FINAL W
I om exempl�nder Sec. Over 5D l0 100 Int. BY n.�
Over 100 N
B.BP.C.for Ihis reason � Z
� Date: Services,Swbd.,MCC 8�anelboords , � .
�. 0-200 Amp.Under 600 V
SignaNre 401-1000 Amp.Under 600 V .
❑ � Over 1000 Amp.or Over 600 V ', _
Exemption for Reg.Mainl.Elect. ?
. SINGLE FAMILY Temp.Power Pole 8 Appurtenances 15� �+ 3� �a r
�'� HOME OWNER-BUIIDER DECLARATION Sign with One Branch Circvi� ' � 7 3'2 A
I N e �,y affirm tha�I am e.empt from the Conhac�or i Llcense q ��on I Si n B a rculs • • • �• a
Law�or the following reoson(Setlion 7031.5,Business and � �Q, �1��� { � 2
ryPro�fessions Cade�: .�� O L•-�5 5 co 6 �� . � p 5 5 0
� L C i. I,as owner of the property,will do the work ond the M;sc.Condui�s 8 Conductors
, � `strocture is not iniended or offered for sale(Sec�ion O�her(See Comple�e Fee ScheduleJ_ ► �� � Q ra 5 Q x
V
7044,Business and Proiessions Code). �9�$-a 6
CONSTRUCTION IENDING AGENCY
I hereby offirm that there is a consiruclion lending ogency for "
Ihe performonce of ihe work for which this permii is issued PERMIT FEE (Svb-Tolal) �� O
(Sec.3097,Civ.C.). f�
� p �I � JJ PIAN CHECKING FEE �� � '
lender'e Name�� �'I ht0 /L �
� G� PERMIT ISSUING FEE �� d �
lender's Address J • ���S,Q
. I cer�ify thof I have�eod this pplica�ion ond sta�e thot the TOTAL FEE �
above in(ormafion is rorrect.I ogree fo comp�y with all County
ord�nances and Slote laws reguloiing Electricol wiring,ond , �
. hereby au�horize repre eniatives ol this County io en�er upon
the a�-mentioned r erry for ction purposes. SEE REVERSE fOR EXPIANATORY LANGUAGE
Signatu�e Permit ee D� .
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, _,:;. . -;.� :. . . , _
. . . .. . . . . � . _.. ��v�rci.� �i�a�.. . . ." . .._ .. -. r �O'J�lN:R-BUILDER DECiARATION
: . ' : .' '. � qFvROVhLS ._DAlE SIGNATI)RE . - .- .-- - -. . _ _ ._. _ i:. ��_', :b . . . . .
. '..•', . �•� ��.-. •...TEN�'.PO'JJERfOI[. � I . .._--- . . . . . � �', .Lic nsovlaw'�for�Ihel;ollowiem�a,o•�on (Secfion 703I.��
� hc CoNrac'or'
; � ��� �- � , � UNDERSLA9 WORK �� - � , , � . �'Boslnnss arc.^rofes:lons Codc):Any dty cr wunly wh�c6
�'�rgqUti e5 c pOrrrtlf fo�consfruct.affcr�impra�e�domolish,
. . . . � . . � �� kOUGH CONpUlT . . .� . � . , , .'`� .
. - -� i - •or repvlrany�efrudJrr,prlor fo�lts issvanco, cho rr
. -- � �- '�\VIRING � � -� qvlrnslfiaopp6m�Horeuchperm�7lof+leaslgnedsfafe�
� �_t� _,�� �. � �--- � ' mcnl N;c}6e is l�rensed pursuaN to the Frovfsfcr,:oi fhc
- �- FIXTURES � , � � _ � . . -,Contractar's Llcensn iaw(Chapter 9(cemmencfng wnh
't 9 � ��� �[,E�6�^ — )
. . -- . . :. PO'J"'�R�AUTHQRIZED t Secfion 700C of.Divisfon 3 of the Ausirtezs ond Profes�
UTILIN CO.NOTIF(ED p � , � . s�ons CodoJ or 16a!ho Is exomp�therefrom onrl�he basls
._.. .. ... . . . . ... . ('!cZ7 =��14�i^ . , fo� 11:= al(ogod ezompNon.�Any violc'ion of Soc!I�n
FIAIAL � �'y�nrzf ... . ---- " .. - � 703i.5 hy ony oppliconl for a permil subjocis fhe oppl�� ,_
__. _ _. . _ . ._ _ �n�ar o . can}}o c tivl/pan�!!y cf not more N�on livc hondred
'. ' vOiES -�-' -� ' dollan(SS00).: � �
--...___. ___ . .._ _ . . . .- -- -- . : , � . .. .
�! � ' �' - ' ;[J'I,as owncr�af iSo pro�erry wiil do ihe v,r��nd
t � � .ihestrutturo is not:nMed�d or offored for sala �
' I � �� . � - - , � . . .. . . (Svc.iO4{;g�siness and Prc(ess(ons Codr. The Can>roo
-- - -- - � �lor i Llconse Lew do�s nof oppfy lo an owner ol ptoporty
`( �, �, ' � . .,,;', .:..-�• „. , who bullds or�7rnprov�s}hvreon, artd who'does sucb
� -� -' �� � '� � � work himial/provided fFni wch Improvements orc not
� � �- " �� �. '� �J'�' � � ��� � � ���'- , ------ - ; ��-- �� � � � tr.fended orofFeredfor svle.1!.'howeve-,fbe bullding or
. �..... . .. ..... . ........ .... ..�.� . .-. . . � � improvemeni!s sold wi}hidone ycor of mmplefion.!hc
; � � • � ' � ' ' �owaor-Eu71d^tv�lU have ihe 6�rdon of prcvin�tfiaf hrt did
. . ' '..' . . . . , not'�vulld orlmprovc/or ffie purpasd'of sale.) . . .
. � , . .._. -'.-- �'- - � . . . �:.,;�a;ri;exaTnPlunderSec.. ""-�.
� ._ . . �. �_ ...� . .�� . . .. . � . ._ -� . ._6 8 P.C.for.ihis reasan � � ' .
: .. .._.. . . ._. . . .� - � �--Dole
- . . �r, . ,,l - . O�.vner . � . � , . .
, � . . ._ ._ _ :�r . :� .. �.. . . . . - .. . . � ' � . � -' .
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