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1460A (13)
WOIiKERS'COMPENSATIONDECLARATION 78A663 ,o�e� qppLICATiON FOR ELECTRICAL PERMIT � . I ItiEreby effiim ihat 1 have a certificate of consent to SeIF insure, CE-8o6G or a'certi��ca,e oF Workers'Compensatbn Insurence,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY cop�j��^.p�/J b.C.) � Q� I 1 A 1 �� / Polic o. -' -- Cpmpa „ r�� h �„ FOq APPLICANT TO FILL IN JOB �p S �/ /�++��8Gr �I �'Certified copy�is hereby turnished. EACH NO. . �g AooRESS p � � � _ ., New Residential Bidgs.&Pools � .Certiifed�copy is Oled with the county bu�l�n9 i pecti 1 8 2-Famiiy,Sq.Ft. ' ' S — S LOCAUTY �u�xd ��f� .. ,department � Multi-(amily Sq.Ft. � — NEAREST " p�� CROSS ST. ' ate 7—u ''�+ Applican ResidentialSwimmingPools OYlNEROR � ,�/°� _ F��M�ME l3�u.k �,�F A.xwc c� !� RTIFICATE OF EXEMPTION FR M WORKERS' putlets:Rec_Light_Sw.— ��� GOMPENSATION INSURANCE ADDRESS �S.-l'��✓ 6 F�. (Thls seetion need not be comdeted it the wak Involved by the Flrst 20 permil is 1or one hundred dolWrs�$100)or lese.) . Total No. Additional.. GTY L�S�r� C 4�$ Tel.No. Z _33 Z I Cef[ify[hat in Ihc DCfformanCB O(thP wOrk fOr vfiich thi5 permit , PLAN LHECK ^ , � is issued,I shall not employ zrry person in arry manner so as to � �- � " - APP�iCANT 4� become subject to the Workers'Compensation Laws. L'ghting Fixtures Firs[20 AODFESS - �� � �� TotalNo. Addilionai Date Applicant - � CITY. • .... Tel.No. NOTICE.TO APPLICANT: If, after makirg this;GertiliCate of Fixed Apptiances Not Over t HP pER�ai7 �{f 'T T Exemption,yrou should 6ecome subject to the Vlorkers'Compensation Range_ Heater_D W. _ AvpuCANT/�((R�.-/�t S �l s .l-�1C• provisions ot the Labor Code,you must forthwith compiy with such � - Oven_Oryer_ VlM.-_ - -� AODRESS �(�� r3y�[ 8 t f p� �� � ,�provisions oi this�permit shall be deemed rewked. Top' _FAU _ W.H._ CRY s�C !�9S Tel.No.��9 �2? I `LICENSED COIITRACTORS DECLARATION � Hood— Fan _ Other_ � � � � � I hcreby a!firm that 1 am Iicensed uMer provisions of Chapter 9 LICENSE OH q /� (commencing wilh Seclion 7000)oF Division 3 01 the Business and -Disp. — Room Alr Contl. _ REG.uuonsER 1 7 ��az%l.�� Professions CoCe,ana my fcense is in full foroe and eFfxt:� po�r Apparatus 8 Large Appliances DiSTRiCT NO. PRocE55 Y � q '] /'[' Size 8 Type HP,KW,KVA,or KVAR 'O � �11�� � License Nu r � `� ` �� Lic.CIas9-v��b. . Up to 1 Incl. FlNAL - Over 1 to tOlnCi. �A� f � / VALIOATION � CoMract -Date - � �Oyer 10 to SO lncl.� FINAL 1 ~ ❑ I am eic.,.ipt under Sec. q pver 50 to 100 Inc. pY /� W B.&P.C:tor thi�reason Over 100 � � , � � � � � � Services,Swbd.,MCC&Panelboards � .. . � . Z - Date: 0-200 Amp.Under 600 V ^ Signature .. 201-1000 Amp.Under 600 V _ ,_ ___._ _,_ ._, . _ _ ❑�� � � - � � . � Over 1000 Amp.or Over 600 V ' Exemption for Reg.Maint.Elect. � -- SRJGLE FAMILY � � Temp.Power Pole 8 Appur[enances . HOA�E OWNER-BUILDER DECLARATION ' �$ign viith One Branch Circuit -�- -" - -- �- � - � ,� 1 heie6y affirm ihat I am exempt from Ihe Contiactor's License Law � r., �n�r...,�.. y 2e,.cn(S^..,.on?.,31.5.�ua.,.,,.,,,,.�F'�a..,sions . Additional Sinn Brench Ciraiits � CodelV . .. - .. . . . .. _ . . � .Misc.Conduits S Conductors ... . . �� 4�0 A I,as ewn=r ef th=preperty,rii!I do Ihe work and the s'.ruc!ure is not intended or ollered lor saie(Section 7044,Business Other(See Complete Fee Schedulel_ . � ^ � � . . . .� and Professbns Codel. � - ..-. . . - ' .. . . . . . CONSTRUCTION LEN�ING AGENCY � � • •2�3 5 O ... . . .. _. _ . . . . .. . . . .. I hereby alfirm Ihat ihere is a construction lending agency for the �- � � N-- performance ot Ine-work For which this permit is issued(Sec.3097, pERM1T FEE ' (Sub-Totaq � � �2 ��` Civ.CJ. _ . . . . . . . . ... , PLAN CHECK�NG FEE 0 9•0 8—8 8 .. . . _ .. .. .. .._ .__ . . . . .. .. ... Lentler's Namo -- �- - PERMR ISSUING FEE O � Lentler's Address �- � � ���� - -- - � � � -- - � � � I certify that I have read lhis apptication and state that the above TOTAL FEE inlormation is correct.I agree to compty with all County ordinances � -- - - - � � �� - and State iaws re9ulating Electrical wiring,and hereby aulMrize representa!ives of this Coun y to ter upon the abare-mentioned�- -- � �-�� �- ��----= ������ �- - -� � � .. . _. . proP� for insPP ion u �S. - .. . ... .. _. . _ SEE REVERSE FOR EXPLANATORY LANGUAGE . . . . . . . _ ...... - -- - - . ._.. ig tur 1 Permntee Date ��;�¢ •�,..� r:�, t—_ _.. ... _ ..._ _ v... . � �1- ---r �• �i._ .� i �—L': --�----i �, ``,' h� ' I I ��"' � � � r � � Ir1^, I• ��: �' � i��j ! �:i !',` � `-�i ,'., I_ i i � ,�,� � �;• • - I` � � ;:i I ! :.•f.. ,' � ' j j ; �� . �. � , . '��--- . 1 ; { . . . . , - ' 1 '� � � � il�t.. �; I . , . :`� . . ' �rt I I j •r�:.�• ': . ;� �r r � ' ;._. � - j �i�- i � ;� . . - ;��. 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