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� WORKERS'COMPENSATION DECLARATION ��3 ,o,e� APPLICATION FOR ELECTRICAL PERMIT �
I here6y affirm Ihot I have a tartifica�e of consent la self. CE�806C'
mswe,a�a certificaie of Worke�s'Compensaiion Insurance, CQUNTY OF LOS ANGElES BUILDING AND SAFETV
or o cartified co�pfyI rtheraof 3800,Lab.C.)
, P❑olicy No. u✓1 om�onyJ�L����p FOR APPIICANT t0 FILL IN � // /_ �y
Certified copy is hareby furnlshed. New Resideniiol Bldgs.� EACH NO. F{,E �ORE55 (!/ �
. � Certified copy is filed wiih the r I ' 1&2-Family,Sq.ft. S = E �OCALITY
�ion department UP MuNi-family Sq.FL �RO55 Si.
Dale��_ApplTaet Residen�iol Swimming Poois , ��gN�
CERTIFICATE Of E%EMPTION FROM WOR R 'y I M.4�1 r
Oullets:Rec�Light_Sw.� AppREu
COMPENSATION INSURANCE Fir:t 20 �'7S �7
(Thi�uciion na�d not b�compl�t�d ii th�work inrelwd 6y Totol No.� - Additional QTY Tal.No. ' �
� fh�p�rmif ls lor on�hundr�d dollm�(5100)er Ina.) ,
1'LAN CHECK
I certify Ihot In the performance of the wark for which this A�Li[AM
permil is issued,I shpll no1 amploy ony person in ony monner � �
50 os to become subject�o Ihe Worke�s'Compensa�ion lows. ��9hting FizWros First 20 ADDRE55
� � ' Tolal No. Additionol
� CITY Tel.No.
, Date applicoN Fixed Applioncas Nol Over 1 HP pER�nIT
NOTICE TO APPIICANT: If, pfter moking Ihis Cerlificate of qppi��p,ryT
Exemprion, you should become�su6jac� to the Wakers' Range_Heater_D.W._
, Compenwtion provisions of�he lobor Code,you mus�forlh- Oven _Dryer �W.M.— � ADDRE55
with comply wi�h s�ch provisions o� this permit shall be 7op _FAU —W.H.— . ,
deemed revoked. � Hood _.Fon _Other_ CITY Tel.No.
LICENSE�CONTRACTORS DECLARATION UCENSe OR -�
I hereby offirm ihot I om licensed undar provisio�s of Chapler 9 Disp. _Room Air Cond. — 2EG.NUMBER �� � Closs.
(tommencing wifh Section 7000)of Division 3 0(the Business � DISiRICT NO. PROCESSE�
oad Profess�ons Code�,}a�nd my license is in full fwce and effetl. P�"'°�Apparo�us 8 Large Appl�ances . �
I'7JZ7 S S1Ze g TYPe HP,KW,KVA,or KVAR /�� ~� V
License Number Lic.Closs� � FINAL � '
Vp l0 1 Incl. DATE �j
��'/A' /� Over 7 to 101nc1. � / �� YALIDATION �
CoNrotlor�^�'�-�""�`-'�'� Dote Z'G Over 10�0 50 IncL FINAI ,Q V
❑ I om exempt under Sec. Ovar 5p to 100 Inc. BY/7<�_ W
L/�Q�� y
B.BP.C.far ihis reason �VB���� . ► Z
Dafe- Services,$wbd.,MCC&Ponelboards �
' 0-200 Amp.Unde�600 V �,
Signature 201-1000 Amp.Under 600 V � � � -
❑ Over 1000 Amp.o�Over 600 V
E.empiion for Reg.Moint.Eiect.
� SINGIE FAM�LY Temp.Power Pole&Appurtenances '. , . . _ �
HOME OWNER-BUIL�ER DECIARATION Sign with One Branch Circoil �1 4 1,8 A �
I hereby offirm Ihot 1 am exampl irom the Contractor i License Additional Sign Brpnch Circuits
low for the following reason(Settion 7031.5,Businass and � �+� � � � �2
Professions Code):
❑ I,os owner of the properly,will do Ihe work ond the Misa Conduils&Conduclors �:• •9 cJ.(�(�
structure iz na�in�ended or offerad for wle(Sec�ion Other($ae Completa Fae ScheduleJ_ � . _
� 7044,Business ond Professions Code). '9���-�
CONSTRUCTION LENDING AGENCY Q'L Q�J—$[�
I hereby affirm�hat ihare is a consNoction lending agenty(or
the performance of 1he work for which Ihis permif is issued PERMIT FEE (Sub-Tolol) � � -
(Sec 3097,Civ.C.�. � '
��i�`,f� PLAN CHKKING FEE � � -
Lender's Name �n ,e< �<,.�^ }� PERMIT ISSUING FEE - Q
Lender's Address "/���7 j�c� #�J �
I certity fhat I hove read this opplication and siole Iho�Ihe TOTAL FEE �
above info�molion is correcl.I oqree fo mmply wilh all Couny �
ordinonces ond$late laws reguloting Eletlritol wiring,ond _,
� hereby aufhorize repr05en1atives of this Counfy fo enter upon
th ove- entioned pro ty for inspection purposas. SEE REVERSE FOR EXPLANATORV LANGUAGE
6 �
ignoNre o1 Perm� ee Dpte � � �
�. � � APAROVALS DATE � . � � .. . _ . . .•a�^�NER-BUILDE2 D:CLARATION
- � • . _ � . , SIGNATURF � � �
� TfMP.POWER POLE� , I herc6y affirm fhaf�am caempt from the Conrracloi s
�- - — ��� � - Licensa Law for the follawing roason (Section 7031.5,
' . UN�ERSLAB WORK - „ � Buslne:s and Frafesslons Code):Any c(ty or counfy whlch
' FOUGH CONDUIT " . reqvlres a permlt}o tonsfrucf,alter,�mprove)demollsh,
• " or repvlr ony strut}urc,prlor fo 71s�lssucnce, also rc�
- WIRING , , , quirezlheappffcantforsuchparmitlo(Ilevslgnedsfmo-
� . FlXTURES � � . ' , ment fhat he Is fleonsedpunuoM to/he provlslons of ehe .
� � � Confrac}or's Ueanse Law(Chapter 9(commencing wi�h
- �� - PO�R AUTHORIZED � � . Sec}lon�7000)o(D!vlsion 3 of the Buslnvss ond Profes�
slons Code)or tha�he 7i exempt Iherefrom and/ho basis
� �� � — UTILIN CO.NOTIPIED � . � for Iho vlleged cxempllon. Any vlolmlon of SeUion
- -� FlNA! Gn(c�nn yronl 7031.5 6y any opphcant for o pormR su6�ocfs fhe oppll-
.. can�fo v civll penalty of not more ihon fiva hundred
� � NOTES ' � , dolfors(5500).: .
� . �. . � ❑I,os owncr of thc properfy will do tho work,ond
� ' the structuro Is not intanded or offered for salo.
� - , � - (Sec.7044,Busfnoss ond Prafass(orts Coda: The Confroc-
�--�-�� - � - � � - � � tor i[Icenso!aw does not appfy fo an owner o!proporry
__ wfio bWlds or Improves lhereon, and who does such
' ' � work hlmself provfded 1ho!suth Improvemenfz are not
. . . .- � - , infendod or of(ercd lor sale.H,hawever,the bullding or
� - � Improvomenf Is sold wRhtn ono year of complotlon,�he
, , � � owner6Nfdorwlflhavetheburdenofprovingiharhedid
- ' noi bulfd or Improve for tho purpose of sala.)
' I om exempt under Sec. ,
B&P.C..for this reason
Dote
Owner