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WORKERS'COMPENSATIONDECLARATION 76A683 +o�o+ qppLICATION FOR ELECTRICAL PERMIT � � I hereby alfirm that 1 have a certificate oF consent to selF insure, CE•BOSG a a certificate of Workers'Compensation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy Ihcrcoi�Sec.3800.Lab.C.) � PoIiCyN0�59a1836�,,,P�nyl)JOuS?QIAI. \ul_l FORAPPLICANTTOFILLIN . ' •1OB Q3'� ���, �1h� RFA� ❑ Certifed copy is hereby fumished... . . New Residential Bldgs.8 Po/�I�C�C� EACH NO. . FEE AODRESS O v �� Cer�ifetl copy is filed�with the�calnty building inspe ion �8 2-Family,Sq.Ft�y— � Q = S LOCALITY R y2 5�6'� Lp Q � � .� NEAHEST �^ • department. . � . - � Mulh-famiiy Sq.FL CRO55 SL � � �ate 30 �'ppp�i�y�� C Residential Swimming Pools �� � - OwNEa OR FlRM NAME � � CERTIFICATE OF E7(EMPTION FROM NlORKERS' � Ma2 �, Outlets:Rec—l'ght—Sw.— �� •- COMPENSATIONINSURANCE -- -. . - - - - " AD�RESS 3 �fRW('I U - (Thle 9ettion need not 6e completed if the work Involved by ihe First 20 . permR Is lor one hundretl tloliars(5100)or lesa) . Total No. Additional CITY _�S �6� •No.. So-(oo . I[ertify ihat in the peilormance of the vrork(or which this permit �- - - � � AppLICnNT K . � _ is issued.1 shail not employ any person in aM m2nner so 2s[o __ become subject to the Workers Compensation Laws. . L'ghtirg Fixtures First 20-- ADDRESS� . • � � � Total No. Additional _ ��� �� CRY - - -� --- ��� Tel.No. Date Applic2nt � Flxed Appliances Not Over 1 HP NEHMR�� � 4 L� NOTICE TO APPLICANT: N,-alter.making this.Certificate of APPLiCAM � L L C �C Exemption,you shou�d become subject to the Workers'Compensation Range_ Heater_ D.W. _ provisions ot the Lzbor Cod�,you must forthwith comply wifh such Oven_ Dryer_ W.M._ AD�RESS� -�$p .provisions or this permit shsll be deemed revoked. .. Top __ FAU _ W.H._._. . . _ . CITY-C�1� b ,*'?V _ �Tel.No. '-61�6 UCENSED CONTRACTORS DECLAFATION, . Hood— Fan _ Other_ I hereby affirm that I�am licensed under.provisions ot.Chapter 9 uceNse or� L p - Disp. — Room Air Cond.._ REG.NUMBER �Q p 3 Class�-1 Icommencing with Section 70001 of Division 3 of the Business and Pr0(e55ion5 CAde,and r,iy liCense is in}ul�for[e and e}(ect. DISTRICT NO. PROCESSED BY .. Power Apparatus&Large Appliances - .. .. .. . . . � License Number -I I DO o 3 Size 8 Type HP,KW,KVA,or KVAR - � �� �`p(� r Lic.Class �_�V ��Up to 1 IncL � FINAL - 'Contractor ��CC�T��CR� Oa1e� - . �"?r 1 to 101nd. DATE ��O r�� O �75 VAIIDATION ❑ Over 10 to 50 Incl. FINAL V 1 am exempt under Sec. Over 50 to 100 Inc. BY . ,. _ W B.&P.C.for this reason Over 100 ' p� . - Services.Swbd.,MCC&Panelboards-� � �� � �� �� � ��� -Date: 0-200 Amp.Under 600 V , � :� � �.7 f� Z Signature 201-1000 Amp.Under 800 V - �� � � - � - - - -- -- --- � � � � - � � -� � - � Over 1000 Amp.or Over 600 V � �a • • e •2 ❑ EzemPtion for Re9.Maint.Elect. . . . . _. ... - . . ....--.. . . . . . ._._. . _ . _ . � ° � 2�a6 ' �� � � �SINGLE FAMILY����� � � � � Temp.Power Pole 8 Appm[enances HO\1E OWNER-BUILDER DECLARATION �� �� � � � � �� -�-- - � - -� -- - I hereby affirm Ihat I am exempt from the Contrector's Lieense law Sign with One Branch Circuit • o � 2 Ei Ll�J� for Ihe(ollowing reasun(Section 7031.5,Business and Professions - Add�tional gipn Br2nch Ciraiits _ . ._, , .. _. . , , . . Code>: 0 8,G b—F�8 ❑ I,as owner oF the proper�y,will tlo lhe work and the s[ructure Misa Conduits&Conductors� - �- - - � �� � � � � � �-� � � is nat intended or cffered for sale(Secibn 7044,6usiness Other(See Compleffi Fee Schedule)_ , � and Professions Code). - � CONSTR�CTIONLENDINGAGENCY -- - �-- - �- - --- -- -� -� - � I hereby a}firm that there is a constmction�endirg agerxy for�he q , performanCe of the work for which this permrt is issued(Sec.30�37, -. pERMIT FEE �� - � � (Sub-Totap S (6 � -- - - . - . -.' - . Civ.C.1. � PLAN CHECKING FEE� . . ._ _. . Lender's Name PERMR ISSUING FEE, __ . . . _ .�O O . . . . _.. . .. . __ . . . ... . Lendei s Address TOTAL FEE /26 • /� I certily that I fiave read this appliCa[ion and state that the above � � inlormation is correcL I ag2e to comply with all County ordinances � antl State laws regulatin9 Electrical wiring,and herehy authorize representatives of this County to enter upon the ahove•menlioned � � -�� � � � ��� � � � �- - � � � � �- - ���" -� � -' � proper for inspection purpo s. SEE REVERSE FOR E%PLANATORY LANGUAGE _ ... . _.. ... ... . . . .. . ._ _ ��� $' �2 b'" • . Sgnature of Permittee Da e � � ' i�._. . .r.�.,� r... . �--`-�� � i - --k• - •i- •I._-I-i+•1--�- i � _i ���.-•i . � � '- t; ; �:_ '- ' - E . ; � � I � ; i � �` ' �. �� i- � I �:� ; i �- �_` ; ; ;-.-;. ! _ i: : ; ' _ ' I` ; ' � �- ; . _ . i �' � i �_. ! I•.. �' � _ =i I' � - . : I � - - � ' '---�; . �� � _ � I ��, I - � � -; I�-- i li �i.��-i' � �~ � - - � j f= ' I,� I ' ' ! - ' --- � ..- i - � � � i i.- ; ;• �,'. - I :�' .- � . 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