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IWORKERS'COMPENSATIONDECLAFATION 76A663 ,o,B, qppLICATION FOR ELECTRICAL PERMIT � I here6y a}firm that I have a cer�ificate of consent ro seit insure, ce-e0ec � I or a cedificale of lNorkers'Compensation Insurxnce,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY ! copy thereof(Sec.3800.Wb.C.) IPolicy No��'�.�18363Company��U�'A�AL 1�D• FOR APPLIL0.NT TD FILL IN � JOB '�. p I ❑ Certi(ied copy is hereby furnished. _ New Residentiat Bldgs.&�o�ls-���7 EACH NO. .FEE ADDRE55 V\1 \o` S $ tt� � �� Certiliea copy is filed with the count building inspection 1&2-Family,Sq.Ft.,,.6�27_� � 0 _ � LOCALITV -V LO • `� I '. dep3rtment. Multi•family Sq.Ft. NEAREST ,,Q 30 ��C � ReSidenlial Swimminq POOIS oW EH OH /� k' D;1te Applicant FIRM NAME 1�`�{'�I C I �� CERTIFICATE OF EXEMPTION FROM WORKERS' .. � . �� MAIL (� �� COh7PENSATION INSURANCE � Outlets:Rec—Light—Sw.— ' � � qpDRE55 � Q�j [1V�• �� I (This sectbn need not ba eompleted i(the work involved by the Flrst 2D� parmit Is for ona hundred doilars($700)or les9.) Total No. Additional- -� �� �-- GTV 26� .N�.$S�- o � i I ce�lify lh�l I�IFl9 pPf}Orill�nr,g O(,thB Work fof WhiCh�hi5 pCfrni� � . ,. - � ' PLAN CHECK - . IS 155Ued,I 5ha11 rro}em 10 an APPl1�AM � p y y person in any m2nner So as to _ become subiect to the Workers'Compensation Laws. LigMirg Fixtures Frst 20 AODRESS � � � Additional � � - - . . Total No. CITY � � -� Tel.No. Date APp�icant I � Fzed ApplianCes Not OVer 1 HP pERMIT �• � • NOTICE TO�APPLICANT: If, after.makinq this�Certificate of �F FC�R�� Exempiion,you shoulA become:,ubject to the Workers'Compensation Range_Heater_ D.W. _ AP�t1C�NT C -I prev!sions of ihe Laber Coje,you must ferthwi!h cemp�y with such Oven_Dryer_W.M._ AODRESS _� n ,1 provisi0ns or this permit shall be deemed rewked. Top _FAU _W.H._ � � , , . .. ' .. . .�. . .. .. CITY Tel.No. ; l UGENSED GONTRAGTORS DECLARATION Hootl_Fan _Other_ �Nb � S� b 6 f I hereby affirm ihat I am licensed urxler proJisions of Chapte�9 LICENSE OR � DiSp.�—Room Air Cond. _ REG.NUwteEn L O - -c�ass.�-�� . (commencing with Section 7000)of Division 3 of the Business and � Rofessions Code;and my license is in fu!I force and eHect. p�e�p�paretus 8 Large Appliances �ISTRICT NO. PRppESSED BV .. . . ,� _/., .. . . � p�7 (��/�� Size&Type HP,KW,KVA,or KVAR �(� ,�1 �Q L�ense Number ��0 J Lic.Class_I.iL � Q � � Up to 1 Incl. " � -�' � --' FINAL �� � - � � � ��- Over 1 to 101nc1. �A� 2�� YALIDA710N � Contractor'���C���C_�L' �Date� � � � � - - � - O Over 10 to�50 Incl. ❑ I am exempt untler Sec. , Over 50 to 100 Inc. gy AL 'U . ._ ..� . . . . Over 1D0 98P.C.for this reason N � � � Services,Swbd.,MCC&Panel6oards �� - - � ' � ��� - � �- _4� � 6,� �{ Z I - � -�- ----- � - Date: ---- � 0-200 Amp.Under 600 V ^ I Signaturo � � 201-1000 Amp.Under 600 V - • �� • • • �C � --- � - - - Over 1000 Amp.or Over 600 4 f ❑ Ezemplion tor Reg.Maint.Eicct. - � - -- - -.- - - .- . . . . .- _ .( • � � 2 � fj. ' � � -� ' SINGLE FAMILY� �'� � � Temp.Power Pole 8 Appurtenances HORAE OWNER-BUILDER�ECLARATION� � � - �- � - " ---�- - � - � ' �-� ?'� 2��`� I hereby� p � Sign with One Branch Circui[ � � ..tfirm that I am exrm t fmm the Contractor's License Law lor the foliowing reason(Section 70315,Business and Professions Atlditionat S�pn Br�nch Cira�its .. _ , _ , ��,�E+-��y Codel: ._._. . _____ _. .._ .... . Misa Conduits 8 Conductors ' ❑ - .._ . . ._ . .__ . _ . .... I,as owner of the property,wili do the work and lhe slructure . is not intended or affemd for sale�Section 7044,Business O�her(See Complete Fee Schedule)_ � � 2ntl Professions Cotle). � � � � �� � � � --- -- - � � - - � - �- - - CONSTRUCTION LENDING AGENCY - �- - - � � . I hereby affirm that there.is a construction lending agency for the � perlormance of the work for which this permit is issued ISec.3097, pERMIT FEE- �- �- - -� - (Sub-Total)- � C'rv.C.I. .. . .. ... _. . . PLAN CHECKING FEE� . . .. .. . .. . .. . � Lender's Name PERMIT ISSUING PEE _ _ ._ _, ._�O S .. ._ . . . , ,_ ._ , . Lender's Address I certify tha[I have read this application and sta[e Mat the above TOTAL FEE �a.I .. . . .. . . .. .. . .. . inFormation is correct.I agree to comply with all County ordinances � � �� . �-� � antl State laws regulating Electrical wiring, and hereby authorize � representatives of this County to enter upon the above-mentioned -� �- �' - -� � � � � � � ��� �� � '� � �-� � � �� - - prope y far inspection purposes. __ _ . . SEE REVERSE FOR E%PLANATORY LANGUAGE. `�1,� � � _ . . _ _ . Signature of Permittee D e �:,.. .. _ _:: ^�. . ��:.:r - � - - - - ;--- � ....�..-•;---_...�_;__.��_.'--�. �. ' � � ' �, - � 3 1' - - - ,� •� _ I i � _� i - � , � j. i ' j i j ' . `'� I�`' 1: i - . � i . '`- i . I � ' � ' I I � -. � - . � � . 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