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� WORKERS'COMPENSATIONDECIARATION !� ,�,8, APPLICATION FOR ELECTRICAL PERMIT ��✓ �
I hereby ofiirm tho�I hava a certifitote of tonsent to self �'� ����
insure,or a cerlifico�e of Workers'Compensorion Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAfETY
or o tertified copy thereaf(Sec.3800,La6.C.) -
Policy No. Company FOR APPLIUNT TO FILL IN 106 �f
� Cartified copy is hereby furnished. New Residential Bldgs.8 Pools EACH NO. FEE ADDRESS�y , / MORid �V�
� CeNified copy is filed wi�h the county building inspec- 1 8 2•Fomily,Sq.FI. _ - S IOCALITY �� � N� �� -
tion departmen�. ' Mulli-fomily$q.Ff. NFpREST p
' Residen�ial Swimming Pools .� OwNER Ok � � '�/� ,/V eNu�.
,Date Appliconl � FIRM NAME G�/ /JG' e LU M�/V T �
I CERTIFICATE OF EXEMPTION FROM WORKERS' ' Outlefs:Rec�Light�5w.,� ���
COMPENSATION INSURANCE � Aoor+ESS�S S� /L NT�e LV1J.
�Thb�Mien n��d not 6�cem lofad�f 1M work inrelv�d 6 First 20
� � P Y Toral No.�- Additionol D��TMMO/t/T��Pe �',�Tel.No� ��
fha perm��tt for o��hund��d dollvn(5100)or Isss.)
�I ceriify thof in Ihe performonte of the work for which fhis � q�+pp`rj�N7K
'permit is issued,I sholl not employ ony person in ony manner
�so os lo betome subject to the Workers'Compensalion taws. ��9hting Fizlures First 20 ADDRESS �
Addifional
1 ����p-(/ � Totol No. CtTY Tel.No.
Dale__��L_Lf.�L_.Applimnl7�-F�Lec�,�i� Fized Appliances Not Over 1 HP PERMIT
NOTICE O/(PPIiCANT: If, oher moking �his Certifimte of APPIICANT �d"� �ec�,ei�
�E:emption, you shauld betome subject �o the Workars' Range_Heoter_D.W._ n n
Compensotion provisions of�he Lobor Code,you musl forlh- Oven —Dryer _W.M.T ADDRESS� 15G'Q 7�'/��CJ t'N/f1 l-f'
�with comply with such provisions or this permi� shall be Top —FAU _W.H.L CITY Tel.No:
,'deemed re�oked. � - �/V%f} / �/ .{i37C �'
Hood _Fon _Oiher_
i LICENSED CONTRACTDRS DECLARATION - uCeNSE OR �y/
�I hereby affirm�hat I am licensed under provisions of Chopter9 Disp. _Room Air Cond. — � ' REG.NUMBER � ��au•C,r
i�mmmencing wiih Section 7000)of�ivision 3 of the Business - DISTRICT NO. PROCES 8Y ,
Power Apparatus 8 Large Applionces � >
�and Professions Code,and my license is in full force and eHect. - / - �-,±,t� -- O
q n S�ize/g Type HP,KW,KVA,or KVAR�
'License Number•�3N3S/�Z lic.Class u� / � " � � FWAL - � V
_f__ Up to 1 Incl. DATE �
nJ'FCLeG1C/C -?�7�� Overltol0lncl. ?� � VAUDATION
Contracior pote FINAI U
❑ . Over 10 to 50 Ind. .. . . .
I om exempt under$e�, Over 50 to 100 Inc. BY W
4
Over 100 y
B.BP.C.for this reoson . Z �
.. ' �Servi �MCC 8 Ponelboards - � � '�
Date: 0-Z00 Am nder 600 V C C , .
SignaNre 201- 000 Amp.Under 600 V - �
QOver I WO Amp.or Over 600 V ,
Exemption for Reg.Moin�.EIeU.
SINGLE FAMI�Y Temp.Power Pole 8 Apporlenances . . �
HOME OWNER-BUIIDER DECLARATION Sign with One 8ranch Circuit � �
I hereby affirm Ihal I am exemp�from the Conlracfor's License Additionol Si n 8mnch Circuits � � �
!^w!er!he follewing recscn(Se:licn 7037.5,B�siness and 9 ?�� G.�Fi
Professions Code): '
❑ I,as owner of fhe properfy,will do the work ond fhe Miic.Conduils 8 Conduttors � �- ,r�• ° • • •2
sl�ocfure is nof iNended or oNered for sale(Setlion . O�her(See_Complete Fee Schedule)_ , ���• .5 9.7 5
704G,Business ond Prafess�ons Code). � �
CONSTRUCTION IENDING AGENCY _ - . . • •5 9,7 5�
I hereby aflirm�ho�there is a consrrucrion lending agency fo� 2� 7—8 4
�he performance of the work for which ihis permit is issued PERMIT FEE � (Sub-Toiol) � - - �
(Sec.3097,Civ.C.). �
MAN CHECKING FEE � � - -
lender's Name� ' N . � �
�y y�/ �C/IN Ci/�p (. v PERMIiI55UINGFEE r r0 �D .
lender's Address G/'� AL�'1/� .Gr?- �
I tertify�hat I have read�h�n ond state thot the TOTAL FEE � /,�" , Js . . .. .
above iniarma�ion is correct.I agree ro comply with QII County _,
ordinances and State lows regulo�in9 EleUricol wiring,ond .. ,
hereby ou�horize represenratives of this County ro enter upan . '
fh bove•me ione roper y for in tion purposes. � '
SEE REVERSE FOR EXPLANATORY LANGUAGE
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