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,�'ORIiERS'COWPENSATIONDECLARATION 76A6fi3 ppp��CATION FOR ELECTRICAL PERMIT {�
" CE-808G(2�80)
� hereby atfirm that I ha�-e a art�ticate of consent to se�t COUNTY OF LOS ANGEIES ' BUILDING AND SAFETY u
insure,or a cmtiticate of Workers'Compensation Insurance,or � .
a certified copy Ihereof(Sec.3800,Lab.C.) ,
� FOR APPLICANT TO FILL IN �pg .
I� Yolicy No. Company ��y Recidentiel BId9s.&Pools EACH NO. FEE ADORESS I E
❑ Cer[IPied copy is hereby furnished. � 7&2•Family,Sq.Ft. $ — Z LOCALITY (,�[,N� �'A� . .
� � Certified co is tiled viith the count buildin Ins Multi-family Sq,Ft. , � NEA E -
py y g pection CROSSST
� department. � _ Fiesidential Swimming Pools OWNER OR . i�r��U �
� Uzte Applicant /� r1 � FIRMNAME .� !J�
, . Outlets:Rec.{LL�ight ��FtSsi ZO O � qDDRESS � (7JZI �1
, CF:RTIrICATG OF EXE�7PTION PROh1 WORKtiRS' To[al No.s.Z Additional � Q
CONPENSA710N INSURANCE CITY Tel No. }
PLAN CHECK 0.
� (This section need not be completed if tlie work int�Olved ' . APPLICANT � , / / O
6y the permit is for one hundred do�la[s (5100)or 1easJ LighcingFixtures First20 ADORESs
Total No. Additional �
I cercify[hat in Ihe performance of the work for which this Fixed Appliaoces Not Over 7 HP � CITY � 7el No. �
;�� permit is issued,1 shall not employ any person in uny manner VERMI7 �� V
� ��, so as to 6ecome su6ject fo the Workers'Compensation Laws.� Range.,_Heater._,_,D.W. APPLICANT ft� L�� � W
a
Oven _Dryer_W.M,_ ADDRESS . • M z
Date Applicant Top _FAU _W.H,._ _
Hood_Fa� _Other Q O CITY . � Tel No.
� NOTICE TD APpL(CANT:If,after making ihis Certificate of Diep. _Room Air Cond�) v LICENSE OR
Exemption, you should become subject to the Workers' AEG.NUMeER - Cie
Compensation provisions of the Labor Code,you must forth� ppwer Apparatus&Large Appliaoces - �IS7RICT NO. ROC SEo BY
�vith compiy with such provisions or this permit shall be Size&Type HP,KW,KVA,or KVA �
deemed revOked. � , �
� � Up to 1 Incl, ����
� Over 1 to 10 Incl. ' F�Nn.� �
� LICENSED CONTRAC70RS DECLARATION - DATE _` VALIDATION
. Over 10 to 50 IncL � � �
I hereby atfirm that 1 am licensed under provisions of Chnpter Over 50 to 100 Inc, FINAL �
BY
� 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 � G�- , -
effect. Services -
0-200 Amp.Under 600 V
License Number Lia Class � 207•1000 Amp,Under 600 V `���F`F
Contrador - Date Over 1000 Amp.or Over 600 V . r a. � o .2
� HOME OWNL•'R•BUILDER DECLARATION Temp.Power Pole&Appurtenancea
I hereby affirm that 1 am exeinpt from the Contractor's Sig�with One Braneh Circuit � �
, License Law for the following reoson (Section 703L5,Busi- Additional Sign Branch Circuits . � •?C 7 J�Q
� ness and Prqfess�ons Code): . . :7,�(��
Miu.Conduits&Conductors 0 9.��i��
I, ns owner ot the Droperty,will do the w�ork and the Other(See Complete Fe¢Schedulel�
� �structure is not intended or offered for sale (Sectlon �
�044,Business and Professfons Code). . -
CONSTNUCTION LGNDINC A(JENCY �
I here6y affirm tha[ there is a construction lending ugency � �
for th( performance af'the work for which this Permit �s pERMIT FEE (Sub-Total) /9 p � � �
issued SeC.3097,Civ.C..
Lendcr•a Name PLAN CHECKING FEE (One•Fourth Permit Fee) �
� LendePs Address Q v � . . �
PERMIT ISSUING FEE Q -
1 certify that [have read this npplication and state that the TOTAL FEE �',� ' � .
above informetion is correcL I agree to comply with alt County �
ordinances and Slate law5 regulating Electricai wiring, and .�
hereby authorize representatives of Ihis Coun[y to enter upon
the above-mentio pro y mspect�on purpo s. - �
�/��� � SEE'REVGRSG POR EXPLANATORY LANGUAGE . .
� SignatureoCPermittee � � ' � � ,
�
• , i . 01VtiliFi-FSUILUfI:DICLA}:1T10N .
� 1 hc�cby aftcm tlrat 1 am ezcr-ip[Irnm ILi�Contractor�c
. � . APPROVALS C�l1TE I;JS7tCT[JF;'� ' LiCen�c I.�tt' fUr tlic (ull'u•.�'inC ic�SOn�SCClioR 7031.5�
._.....f�'-
sier�arun,[ L'u�i,rr^es and FYof�'ssio�rr Co�le)' Any eiU• nr camp�
- �� � T'[Mf'.f'04VGR F'OLE - ' " i�'l�ic�lt r('quirct c perr�iit fo Curts'tn�:f, c,�ter, in,1Jl/o�'�,
" UND[�SLl��3l'JOfih: _ deir.rifisJ:,<�r re�;,:i.�c�l)�rtn�ctrrrr.prir!!r i:s isst�artce�.
. - -- , . � nlso rc,7iures Nir cppficc.�rt for auch perrrut ro file a
� t70UGH COPJDUIT �� - - . . si,qrrcd staren:ent lhet I+r rs licr�ued purs+�an! to tl:c
� �NiRtNG� � ' i �(��Z3U! �(��G--., , � prnrisiars uf die Corttrerr�r'c I.icerm� Lnn� /Clraprer 9
, ��, . (conur:e�rcin� iritf� Scctian 7000/ nf Diririwt 3 oI tlre
` � . . FIXTURES _ _s- '.-. �. Gusiuesr mrr�I'rof:.criatr CodcJ or 7Lcr he ic�Cxcmpf
� , , ' _ _ fhereJi;�rn arrd 71m b:sic for thca!le.C�'�e.rem,�rtinrt.�1nc
. . -- .f'011'GP.�r.UtHO�RIZE� � i•ir)la7:i��!nf$�ftinrt 70?!.?f�}�C/t)'c,Jpliccr;t f�rc/�crlt�il
. . UTILITY'CO.NO7IFIED � st[Gi.rts tltr er��;ir�ar:1 1u a ei�il J�en;:71}'of rtot 1�t��e fJ;u�i
� �7 . fire 1!:�r.lrcd rlr:!f��7/<iQOJ.:
- . _ _ _���F'INF�L� ` �'i:.tc3 4�= tfa.✓� � ❑1.:�;ov:ncr o[tha proper[y r:ill i:c Ihc i�.orV..;ir�d
.� NorES " � , „ ., U�c struct;rcc is not iatendcd ot o(Icrcd for 5a1:.
.. ._ . _ ..__ . _ � . . (Src. i0-l-F. P.usL:;rs m,�:Prnf:txiwts CoCC: Tkc'Com
. ' '� ,. . , bcrtnrlc Licertce La�c daer nrt appfe to mr o�ir�er vf
l
..,,. , , prnprir} �rlm Guilr.!e or in:prm'ea Uterea�.and whn does
� snd� i.�ord l�inarc!/ yroridcd rlrm si�dt improrcmenrs
' , . ..� . . are no! i��lt�red.'d or offercd for sal�'. Jf, l�oN•e��.•r, tF�r
- , . � hvi';In(_� �r LnprOrcmrirt is solp' �ri7Gir. wte pCc.� of
. , `i ron:p!rfio^. 1Lz o�n:cr-buil:ltr �oill 1t�rc !hc burden
. ` ` '��-' ' "' -. . � � nf.proriri� tltrt hc did itot build or intprore fur d�e
� . E^.trpr s e��tnfr.l ..
-- ` `- ];�m exei:ipt und�r Sec. .
£,F:P.C.fo:thi;ra�>on
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