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1392A
WORKERS'COMPENSATIONDECLAFATION 76A663 10/81 qppLICATION FOR ELECTRICAL PERMIT � � I hereby affirm that I have a certificate of consent to self insure, cE-eosG or a certititate oF workers'Com�nsation Insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy ihereot(Sec.3800p.�La�'b.QC.) � ^ /� �,�j�y Policy NO�LZ,'pmp�ny�L/��'/ FOR APPUCANT TO FILL IN' '' JOB �Certified copy is hereby fumished. , New Residential Bldgs.S Pools �EACH NO. FEE � poDaeSS ,s �� � f �, y,h � 1 8 2-Fami�y,Sp.Ft. � = 5 LOCALITY � � . Cert�Fied eopy is filed with the cwnty buildirg inspection department. . . - �-�^ Muiti-family Sq.Ft. Neaflesr �Y t,y^ /�-J Residential Swimming Pool9 eROSS SL �J� �ir>,S//Rv DatB�APPlican� �� OWNER OR . � » -7 / FIRM NAME � � CERTIFlCATE OF EXEMP170N FROM WORKERS' . � (OS � � Ma� u � GOMPENSATION INSURANGE . OutletS:Re L'ght_Sw. r pDottESS . W` `O.(/,% LV��• .�This secibn need not be completed H the work invdved 6y Ihe first 20 • � �a � permit is tor one hundred ddiars($100)w less.) . Total No. ,�� Additionat CITY j �``/ Tel.No. 1 certify that in the performance ot the work for which this permit � p�nr+CHecK � � is issued,I shali rot emplo ._\ APPLICANT y arry person in arry manner so as 10 S. Zp rU ADDRESS - become subject to the Workers'Corrmensation Laws.. , L'ghtirg FizNres First 20� � � � - ! � Additional � � � � ' � Total No..�?� � CITY - � -�- Tel.No. Dale Applicant -� N � TO APPLICANT: If, after makirg this Certificate of Flxed Appliances Not Over 7 HP PERrniT � /L/// E. �ion,you should become subjed to Ihe YVorkers'Compensation Range_Heater_D W. _ . APt�iCnNT L 7 provisions of the Lzbor Code,you must(orthwith compty wilh such Oven_Dryer_W.M._ A�DRESS L/3 sr provisiong or this permit shnll be deemed revoked. . . . Top. _FAl1. _ W.H._ - - �. qTY ��/Ib(J �-h. Tel.No. �b - . LICENSED CONTRACTORS DECLARATION � Hood_Fan _Other_ �-'y I hereby a!f:rm ihat I am ficensed undar provisions of Chapler 9 _ ucErue oH . (commencing with Section 7000)of Division 3 of the Business and Disp. .—Room Air Cond. �— REG.NUMeEft c��.G D Professions Code,and my license is in fuli lorce and effect. ppWer Apparatus 8 Large AOP��ances DISTRICT NO. PROCESSE�6Y _ . .. � _.____._ _'___.��. . } License Number f7�/�� f) Size,B Type HP,KW,KVA,or KVAR �R" 47! Lk.Class � 0 �j�Up to 1 Incl. - FINAL v ' 1�G i/r /C _4�,L_Over 1 to 10 I�I. . [ltJ DATE ��. -� � �� Contiactor LN F�Date 9���7 � I�_ t!�..-. YALIDATION . � r y Over 10 to 50 Incl. �-. FlNAL , q V ❑ I 2m exempt under Se¢ Over 50 to t001na � 6.&P.C.for this reason Owr 700 BY `Je`"� � N , Services,Swbd.,MCC 8 Panelboards - � � � "� � � � �� Z Date: 0-200 Amp.Under 600 V Signature 201-7000 Amp.Und2�600 V � � � -- � � � ❑ - OvCr 1000 Amp.or Over 600 V Exemption toc Reg.A1ainL Elect. ... ... .- SRJGLE FAMILY- . . Temp.Power Pote 8 Appurtenances . - . . . - . . �� 3 9�2� � \ HOME OVJNER-BU'LDER DECLARAiION Sign wlth Onc 6ranch Circuit 1: {�aflirm ihat I am exempt from Ihe Contractor's License Law f�� .S(..i._.. a ....��.^.:�C...,0:1 7C3......,....���:,.3��i�N�'c'a5iJi15 AAAitinnal Sinn Rrarr.h f�irNiiS . .. __ . . .. ry. . . : :� _ Cotle): ❑ I,zs owner of the property,will do ihe vrork and the structure Misa Conduits&Conductore � . � • 1 5 a 0 0 is not intended or ofleretl tor sale(Seclion 7044,Business Other(See Complete Fee Schedule)_ , • ° � 5�j,0 Q= nnd Professions Code). V o9,0II�87 � CONSTRUCTION LENDING AGENCV �� � � - ' 1 hereby aftirm that there is a cOnstruction lending agerxy tor the � performance of�he work for which ihis permit is iSsuM(Sec.3097, PERMIT FEE�` � � � � � �(Su6•Totaq - �� �, - � - �� - - � � Civ.C.�. PLAN CHECKING FEE ��- ��� � ��� -� � � � � � ��'� � � Lender's Name PERMR ISSUtNG FEE . . . , . . � �D _.. _ . � .. . .. LeMers Address I certify lhal I have read ihis application and state that the abova TDTAL FEE _ !�j��QQ _ , . . inlormAtion is correct.I agree to comply with all CWnty ordinances � � antl Stale Iaws regulatiry Electrical wiring,and hereby authorize , _ . . � � �,�y�e���� � representatives of this Counly to enter upon the a6ove-mentioned ���"/p���� property for inspecfio purpos s. ^� '� - SEE REVERSE FOR EXPLANATOHY LANGUAGE -- ��� ff�,�,�lwrG ���,Q/ l��IR� � —�/— _• � � S�gnature �Permil e Date �L/�y,,e_y� � v 1 ' /'� I � _._.�.• ....r . ... _ ... ... .. . _ .... .1 . . � _— __.'.�'. •.-�� �� -�+--� .i..��.i. �'.1. .._..I�� Mt ._ .. _ � ��r ,=Y � I . i �I � 1 �' : � ;.. 1 , � l �; ;' � I � i— � i ' - !J , _ ty� C�„ li � _ . .� ` -i � _ _ � � � -- - � , = - , !' t ; � N- = , -- �, � _. ., , -- .:.. - � . - - - i ( ' �' , I i , . . ; . •�. � i' n, ,..� � ; _ , ..1 � '2 T C 'V �l 17 C --� � i � � � ; I..' .. 'f Y C O -1 � �C� O � , '^ ', � i • a, r -� m' c -� � m v : , ? 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