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WORKGRS'COAIPENSATIONDF.CLARATION 76A663 � - APPLICATION FOR ELECTRICAL PERMIT � � �
CE-806G 12�80)
1 hereby atFtrm thaf 1 have a certificate oe consent to�s•�t� i COUNTV OF LOS ANGELES BVILDING AND SAFETY
insure,or a certiticate o}Workers'Compensation Insurance,or.;,
a certified copy thereof(Sec.3800,Lab.C.) � - �
� Pnlicy No. Company ' FOR APPLICANT TO FILL IN qD�RESS /
� • . New Residentlal Bldgs.&Pools EACH No. FEE v O c�+n r 81�
� Certitied copy is hereby tumished. . 1&2-Family,Sq.Ft. g — $ LOCALITY )"+
' ' Multf•family Sq.F(. � — NEAR ST '
� Certi�ed copy_is fi�ed with the county building inspection Residential Swimming Pools cROSS ST ,
department. ' � '' . OWNEF OR � 'J/�
/'� �Q FIRM NAME G`�`"� 1
�ate Applicant Outlets:Rec(QDLight.,2Q Sw.� �1 MA�� �
� �7 Firs[2 �"� 5 �� ADDRESS ,D•��•Dj '�1. Y B ;
CiRTIFICATG OF EXEMPTION FROM WORKERS' Total No.�L— Additional � {�� CI7Y ('}kd fpo• } �
COSIPCNSATiON INSURANCE - PLAN CHE K a-
APPLICANT O
(This section need not bc eompleted if the work involved � 'LD �Z n(� V •
b the 6ightinq Fixtures First 20 . qOOREss � �
y permit is for one hundred dollara (5100)or less.) � Additional � J OC
1 certity that in the performance of the rvork Por which this Total No. � ' ��Ty . � • Tel No. U �,
Fixed ApPliances Not Over 1 HP
p e r m i t i s i s s u e d,I s h u i l n o t e mp l o y a n y p e r s o n i n u n y m a n n e r � P E R M I t � J W
so as to become subject to Ihe Workers'Compensalion Laws. Range_Heater D.W,_ � , ' qpvLICANT e L r e"i d �
) Oven _Dryer�W.M._ � AODRESS z9��r �C �'/ Z
'I / �f Y Top _FAU W.H.,� �!,' d (� �3
Da[e �7 ��plicant ��S ��eC` �� C.� - CITY el No. �
� Hood_Fan �Other— q -� �,
NOTICIi TO APPLICANT:If,a(ter making this Certificate nf Disp. _Room Air Cond� � � � `���(J ��CENSE OR �2q�� ��p ,
rxemption, you shnutd become suhject to the Workers' - REG.NUMBER�7VvqW Ci�s �' �
Compensatlon pmvisions of the Labor Code,you must forth• power Apparatus&Large Applia�ces DISTRICT No. PFO�CE/SS/ED BY
avith comply with such provisionc or this permit shal� be Size&Type HP,KW,KVA,or KVA ' /(' , /(�� �'�(�....� � -
deemed revoked. . Up to 1 IneL � u � '
- - � Over 1 to 101nc1. �l � •2 � FINAL ,I „ -
DATE C� J,/ rh' VALIDATION
� LiCENSE�CONTRACTORS DECLARATION Over 10 to 50 Ind. l��•{ /'�
FINAL
I herehy atfirm that I am licensed under provisions of Chapter Over 50 to 100 Inc. BY n( � - ' �
9(commencing wlth Sectlon 7000)of Division 3 of the Rusi• Over 100 �yu. , _g 1 �_2 8� �
ness snd ProRssions Code,and my license is in full force snd � . . �
effect. Q - Services �
?�OD QOU ' �'IO ' AmP.Und r 6 � [` � � � �• •• • •2 .
License NumAer Lta Ciass - '
/ 9 �.,Q 201-7000 Amp.Vnder 600 V , � • � � (�5 O 1
Contracta� s �°e �ate ��1D��{ v � Over 1000 Amp.or Over 600 V � �
• • 11450�.
IiOML OWNER-BUILDER DECLARA710N Temp.Power Po�e&Appurtenances -
I hereby �ffirm'that I am exempt from the Contractor's Sign with One Branch Circuit I Z P�l"ai�
License Law for the fotlowing reason�(Senlon 7031.5,Auci- Additional Sign Brantb Circuits — � � � , �
ness anA Professions Code): ' � . � .
MisaConduits&Conduetors „/�� �Jy ����,��`��3tiJv– ���
, � I,as owner of the properry,avill do the work and the Other(See Complete Fee Schedule)— /`/��� / ��
structure is not intended or offered for sale (Section , ��!!,/.�:=%L
7044,Rusiness and Professions Code). �.
CONSTRUCTION LENDINC A(3ENCY �s
I hereby affirm Ihat Ihere is a construclion lending agency � D�� ��S d� ��/P/�l
for the pertormance of the�vork for which �his permit is pERMITFEE (Sub•Total) � .,DQ
issued(Src.3097,Civ.C.). � . _ -
Lender's Name . PLAN CHECKING FEE IOne•Fourth Permit Fee)
Lender's Address PEFiMIT ISSUING FEE � �S� � .
I certity that 1 have read ihis apptication and state that the TOTAL FEE . ,�3– jQ -
above information is correct.1 agree to comply with all Connty - � �� �
ordinanres and State laws regUlating Electrical wiring, and -
hereby authorixe representatices oP his County[o enter upon . , � � � , .
fhe ahove- nti ned pr rty fm' pection purposes. SEE-RLVERSE FOR EXPLANATORY LANGUAGE . � �
� la a --�I . ,/
Signa ureofPermittee Date � � /�
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