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No Permit Number (4)
WORKERS'COMPENSATIONDECLARATION 78A883 �o�e, qppLICATION FOR ELECTRICAL PERMIT � � I hereby af(irm that I have a certifcate of consent to self insura, �E-aosc or a certi�ic4te o��'rorkers'Compensation Insurance,or a certilied COUNTY OF LOS ANGELES BUILDING AND SAFETY ,copy thereoF(Soec.3800,Lab.C.) T PoIiCy No.C�1 O I�3 G�Cp�jpy�y 1�.)�US 4 Q lQ I. �A1h FOR APPLJCANT 70 FlLL IN . " " JOB L, �y � Certifietl copy is hereby fumished . �.. ; New Residential Bldgs.8 I EACH N0. .FEE �DRESS$ 0 V�Il \-u �S ��� � �� Certified copy is ffed with the cwnty building inspection �g 2•Family,Sq.Ft.�.2_ � �— 5 � S LOCALITY �. 2 S96—V : � - depar�men�. - � / A � ' '� Multi-fdmily Sq.Ft. — NEAREST . . � �I�w '1/-� . Residential Swimming Poals ,� � Ow EN OH 1 D�te.�L��AppliCant 9{�5�.( !� /� � FlRMNAME.� [-rY+1�4C � CERTIFICATE OF EXEMPTION FROM WORKERS' - - p�tiets:Rec_L'ght_Sw.="-" ' � � � MniL u p � -- � COMPENSATIONINSURANCE � � .� . - � � � nooaESS S � 'R�11 UN� IJ (This seetlon need not be completed if tbe work invdved by tha Frst 20. Total No. Additional ��� CITY U���r,'� S 26�(,ei.No.��_ o0 permlt Is tor one hundred dolla�s(4700)w less.), . -1 certify that in the performance of the work for whkh this permit ' .... � � ; �+; . �� �'�appLN1Cc�rv�K - - . . is iswed,I shatl not empioy arry Derson in any-manner so as to . - become subiect to the WorkeB'Compensation Laws. L'ghting Fixtures Flrs[20�� AO�RESS � - . � Additlonal_ �" '� � � �� - � � ' � Total No. CITY - � � Tel.No. �ata -� Applicant � � Fxetl Appliances Not Over 1 HP PEfiMIT � NOTICE �TO APPLICANT: I}, alter-making this_Certificate o� ����ANT h CC' � �\���`��C Exemption,you should become subject b the Nbrkers'Compensation . f�ange_Heater_D.W. _ _ provisions of the Labor Code,you must forthwith comply with such Oven_ Dryer_W.M._- A�DRESS 'e,(�_ l(�aX prOvisions or this permit shall 6e deemed revoked. . Top _FAU _W.H._. -.. p. UCENSED CONTRACTORS�EGLARATION , Hood_Fan _ Other_ ��TM ��N� ,�b:l Tel.No.� _ I hereby affirm that I am licensed under provisions of.Chapter 9 . uCENSEOR �,/ (Commen[ing With SCC�ion 7000)Of DiviSion 3 01 ihe Bu5ine55 2nd --DiSp. —ROOm Aif COfld. _ REG.NUTABER� / oo�3 - ���s� C—�a Profe55i0n5 Code,and my license i5 in full torCe and effect. o15rnlcT NO. PnOCESSED BY . Power Apparetus 8 Large Appliances - _. _.. . /�' , _ _ O � (J q c�, (`���' Size 8 Type HP,KW,KVA,or KVAR �v �1�h � License Number I !�a O� Lic.Class�� - � � - � �Up to 1 Incl. � �� �- � � FINAL- � - - � V �FI EC�f C fa� �� � Tq. Over 1 to 10 IncL �A� Q . VALIDATION 0 Cont2ctor Date Over 10 to SO lncl. U FINAL ❑ I am esemDt under Sec. . Over 50 to 1001nc. _ gy . . W � B.SP.C.for this rcason - Over 100 N . . SerJices.Swbd.,MCC 8 Panel6oards � -� � � --� � - - � - � �- Z� - -Date: " 0-200 Amp.Under 600 V , • Sign2ture � � � �201-1000 Amp.Under soo v - - - - � � � -- - :�1 1�8 9 A � - � - - - � - �- �� - ��---�- Over 1000 Amp.or Over 600 V � � .Exemptbn for Re9.Maint.Elect . . . . .. - . .........-�----.....--------�i{• • • •a� � �S!NGLE FAM!LY �� � Temp.Pownr Pole 8 Appurtenances _ - ._ ., _ ... . . � • 1 2 b 4 6 - HOME OWNER-BUILDER DECLARATION Si9n with One Branch Cireuit � I hereby altirm that I am ezempt from the Contractors License Law � ���i ,:�_ , for the follrnvin��Pasnn�Sactinn 7031.5,Bosin?ss 2nd Prcf=��?on9 ��- Additional Sgn&anch Cirwits �� � � G_ .... coeel: 0 8 P b-S£3 ❑ I,as owner of the property,wiil do the work and the structure Misa Conduits&Conductors - - - " � � � �� � � - � � � is not intended or ofle�ed for sa�e(Section 7044,Business Other�See Comptete Fee Schedule)_ . I and Prolessions Codel. ► � CONSTRUCTION LENDING AGENCY I hereby affirm that th2ro is a wns!nxtion lending agency for the � pertormance of the work for which this permit is issuetl(Sec.3097, - pERMrc FEE ' -�-'� ISub-Total) �S 6 �� - � � � Civ.G). " PLAN CHECKING FEE�� � - �- � � � -- --� �� �- - �� � Lender's Name PERMIT ISSUING FEE . � - - . -- -- �p O � �� � � � - . .. Lendeis Address � � I certify ihat I have read this application and stato that the above TOTAL FEE _ _ ��j. / • . . ., - . , information is correct.I agree to comply with all Cwnty ordinances and State laws regulating Electrical wiring, and here6y authorize .. _ . _ . _. ,_ , . . , � represe�tatives of this County to enter upon the ahove-mentioned � � propp ty for inspection purposes. � - ---�� ��- -SEE REVERSE FOR EXPLANATORY LANGUAGE �� ..- - . . _ . � � 2� Sig ature ot Permittee D te � . ...,.. _�.�_:_. 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