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WORKERS'CObfPENSATIONDECLARATION 76A663 � �7
I �E�o6�,z.so, APPLICATION FOR ELECTRICAL PERMIT � ��
� hereby affirm that t have a certificate of consent to self • COUNTY OF LOS ANGELES BUILDING AND SAFETV �,�
' insure,or a certificate of Workers'Compensation]nsurence,or - � � . �
a certiCed copy thereof(Sec.3800,Lab.C.) �
(y��Y Z STRTs� ��Np I FOR APPLICANTTO FILL IN �pg
I PoIlcyNo. �r � Company ' EACH NO. FEE A�ORESS S� D D/vD BAfL ISLL�D
e � New Residential 81dgs.&Pools .7 v
Certified cnpy is hercby furni5hed. 1&2•Family,Sq.Ft. s — S, LOCALITY �y ,e.b� ])�pA2 $
I Mutti-family Sq.Ft. � N A
� Certified copy is rled with ihe c�unty M1uilding inspection�• CROSS ST
department. � ,� Residential Swimming Poo15 OWNER OR
Date 2'Z���Applicant �nA���L COI.1S/� ,, FIRM NAME E7!/t►�6EL1CA4 IZ� CNl/RCi�
' Out�ets:ReeQ�l.ight�Sw.3S U� MAIL �y�p�
CGRTIFICATE OF EXEh1PTION PROM WORKGRS' ; �S.T First 20 AODRESS��'
Total No. Additional CITY D,y�m�p g��- Tel No. $�$"r J }
. COMPENSATION[NSUR�NCB � �
PLAN CHECK a
(This secNon need not be compieted if the work invo�ved I y v�APPUCANT EYL— p
Li htin Fixtures First 20 � 3 k� U
by the permit is for one hundred doilars (S100)ot less.) 9 9 �4DDRESS . .
I Additional Ln+ L Y�
f certif that In the � Total No. �*Z- � . �
y perfmmance of the work for which th�s 'I Fixed Appliances Not Over 1 HP CITY �.W�y,N�M Tei No. _d—rr�Z, O
permit is issUed,I shall not emptoy any ptrson in any manne! , PERMIT
so as to become subject to ihe Wotkers'Comprnsation Ln�vs. Range_Heater D.W._ � APPLICANT L 5 Z.. � W
� � � Oven • Dryer_W.M._ �
A�ORE55 ���Tj k�R� gL , y
Date Applicant � Top _PAU �W.H.L . �Z
Hood_Fan 1�otner_ ciTv �q�� Tel No. '�^t ,-0�sL
NOTICE TO APPLICANT:If,atter making this Certificate of Disp. �Room Air Cond.`�� �LiCENSE OR �l ^f
Exemption, you sl�oulJ become subject to the W�rkers' REG.NUMBER 5�'7$ L Class $"
Compensation provisions ot the Labor Code,you must forth- . power Apperatus&Large Appliances DISTRICT NO. PROCF+6SED BY �
with compiy with such provisions or this permit shall be 5ize&Type HP,KW,KVA,or KVA �� �f �
deemed revoked. F) 0.����
� Up to 1 Incl.
FINAL
LICENSED CONTRACTORS DLCLARATION ��r 1 to 10 Incl. � OATE / a� b VALIDATION '
Over 10 ta 50 Incl. U
I hereby affirm that 1 am licensed under prorisions of Chapter Over 50 ta 100 Ine, FI NAL � -
eV
9(commencing with Section 7000)of Division 3 of the Busi- Over 100 �
ness and Pmfessions.Code,and my license is in tull force and �
effect. Services . - � �
License Numher 0.200 Amp.Under 600 V S C
s e�- Lic.Class ��� 201-1000 Amp.Unde(600 V
Cnntractor�J�}�EQ � Date_Z'Z�'� Over 7000 Amp,or Over 600 V _ . •
HOMF.OWNER•RUILDER DECLARATION Temp.Power Pole&Appurtenances � . . � .
1 herehy affirm Ihat I am ezempt from the ContractoPs Sign with One Branch Circuit � . � -
Licenu Law fnr the following reason(S?ction 7031.5, P.usi- Additional Sign Brench Circuits . " . � ���6 5 6 A
ness and Protessions Cnde): . A � �
Misc.Condui[5&ConductOrs(��""r � � �' � . . �;���'• •'�2
� I, as owner of the property,will do the work and the Other(See Complere Fee Schedulel— �
structure is not fMendtd or otfercd tor saie (Section ' �� • � 6'7� Q
7044,Business and Prnfessions Code). �
CONSTRUCTION LENDING AOENCY � , . - ''�• � (��Z� O�
1 here6y affirm that there is a construction lending agency � � �
for the performance of the work for which [his permil is pERM1T FEE (Sub-Totall O 2 2 4—$2 . .
issued(Sec.3097,Civ.CJ. � . _ Sy �
Lender's Name PLAN CHECKING FEE (One-Fourth Permit Fee)
Lender's Address PERMIT ISSUING FEE �i /
J S
1 cerNfy that I have read this applicatinn and state Ihat the TOTAL FEE � �4? �� �
above infnrmation is correa.1 agree to comply with ail Cmmty �
ordinan and State laws regulating Liectrical wiring, and . . �
hereby horize tepresentatives of this County to.enter upon � � - .
the aA v me ioned property tar inspection purposes. � SEE'REV ERSB POR EXPLANATORY LANGUAGG � �
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