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� '"°RKERS`�°"'PE"SAT'°"°E""RAT'°" `' ` p�'"°""�,87 APPLICATION FOR ELECTRICAL PERMIT
..76Afib3 `\.
I hereby affirm that I have a wrtiffcate of consent to self �E.� �.,
insure,or o certifico�n of Workers'Compensation Insuronce, COUNTY OP LOS ANGELES DEPT.OF PUBIIC WORKS
or a cenlfied copy thereof(Sec.3800,Lab.C. j �
Polic No.�� '-� Com an �� �� €-� - FOR APPLIGhNT 70 FILL IN 10B � /� ,
Y P Y ADORESS I� •!�Y'iMor,t� Cik:^ �`111L'I� r�.
�Cenified copy is hereby fumished. � New Residenlial 81dgs.&Pools EACH NQ FEE .
Certified�copy is filed with the�county building�nspeo- 1&2-Fpmily,Sq.FI. $ — S LOCALITY � j G�. �,. "�a,�^ '
�tion deparimen�. Multi-family Sq.Ft. — NE,4R[57 ,
� CRO55 ST.
��4-f� *�,�, '/ Rasidential Swimming Pools OWNER UR
Oote-`� Applicanl. FIRM NAME _:�1h� .�I • -
���/g�_CERTIFICATE OF EXEMPTION FROM WORKERS � Outlets:Rec�.ligM_Sw._ � qoDRE55����'a °s. ' t�P. i..�k�.fa� 1� ` kt��f �
��Y COMPENSATION WSURANCE First 20 �� ,?
(Tbis secfion need not be completed if}he work involved by �Total No. Additionai CITYS ,�:� �L� Tel.No!C _,!!•
the permit is for one hvndred dollors(570D)or less.) , pLAN�HECK
I certify Ihal in ihe performance of ihe work For which�his APPIICANT �
permit is issued,I shall not employ ony person in qny mariner ��Lighting Fixtures First 20 ADDRESS �
so as to become s�bject ta�he Worker.z'Compensmion Lows: �
� . Addition�l
� To�al No. CITY Tel.No.
Date � Applicont � ��Fixed Appliances Not Over 1 HP peaM�T .
NOTICE TO APPLICANT: I4,'after making Ihis Cerli{�cate of qppuCATION t2Q -- ''�t` xr'R�ha+. �
Exemptfon, you shoald become sub;ect �o ihe Workers' Ronge— Heater—D.W. _. �� �
Compensotion provisions oi the Labor Code,you must forth- Oven —Dryer --W.M.— ADDRE55 ct�C' 'Sn ,�.•
with comply with such provisions or this permit shall be ; Top — FAU —W.H.—
deemed revoked. CITY �� , ��� ,� • ^Tel.No.t�(�-�ti,'�,�,�� z
LICENSED CONTRACTORS DECLARATION � Hood —Fan --_-Other._ ' , :
� Diso. _ Room Air Cund. — '�tC'cNSE OR �^-;-Fy��
i here6y affirm that I am!icersed urder provisions of Cnapler 9 ; , ReG.NUM9Ee 9 � Class,}3 ��� �'
(commencing with$edion 7000)of Division 3 of.the Business „power AppowWs&Large Appliances DISTRICT NO. P OCESSED Y �}
ond Professions Code,and my license is in full force ond effect. _ �a �y� .;� ,
, ���p�-�/ � Size&Type HP,KW,KVA,or KVAR
License Nomber_�r�aa t.��Lic Class � ��;� i Up to 1 Ind. fWAL ..
� / j r Over 1 to 10 Incl. DATE� ! �'� VALIDATION A d
Coniractor ���'���✓/,�� �' Daie �` . F'�,�� < < `� ;.F-
. r �' Over iQ to 50 lad. FINAL
❑ I am exempt under Sec. �; Over 50 to 100 Inc BY j�` r ,°;a
B.8P.C.for�his reason Over 100 '�•1✓� ,��
� � Date: �'Serviees,Swbd.,MCC 8 Panelboards � . '+�,Z
�0-200 Amp.Under 600 V
�. Signature 201-1000 Amp.Under 600 V
t O O�er 1000 Amp.or Over 600 V
f-,!, Exemption for Reg.Mainc Elecc �
� SINGLE FAMILV xTemp.Power Pole 8 Appurtenances
HOME OWNER-BUIIDER DECLARATION ��Siqn with One Branch Cirwit
1 hereby offirm'hm I am exempt from ihe Comroctor's Llcense i: �
Law{�r ihe following reason(Section 7031.5,Business and -Additional Sign Branch Circuils _(1 :;�.(,'F.
Profec.sinns Co�:)
�� �'�Misc Conduifs&Gondudors y7�- a a 4 u 1
� ❑I,as owner of the property,will do Ihe work and 1he
strudure is not intended or offered for sale(Section 7044 �Other(See Complete Fee Sthedule)_ ', � m � � `,�h C
Business and Professions Code).
CONSTRUCTION LENDING AGENCY `.'? '��G,s
I here6y affirm that�here Is a mnshuction lending agency for '
�he performanca of rhe work for which this permit is issued PERMI7 FEE (5�6-iotal) �P�� � �—U�
f (Sec�3097,Civ.C.J. ':
� ', . � PLAN CHECKING FEE �. , '
Lender's Npme ,s� .
' � . PERMIT ISSUING FEE � �
Lender's Address Q �'�
� -�� I ceriiiy that I have read thls application and stoie tha�ihe TOTAL FEE Q; .
obove informa+ion is corren.I ag�ee to comply with oll County .,
ordinances and Sta�e laws regulating E�ecirical wiring,ond
hereby au�horize re�resentatives of this Cou.nty to enter upon .
ihe above-fpentioned property for inspection purposes.
� SEE REVERSE FOR EXPLANATORY IANGUAGE
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