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1722A (10)
WOFKERS'COMPENSATIONDECLARATION 76A663 ,oie� qppLICATION FOR ELECTRICAL PERMIT {� , 1 hereby ajfirm ihat I have a cert'rficate of consent to self fnsure, cE-8o6G or a certificate of Workers'Comcensation Inwrance,or a certitied COUNTY OF LOS ANGELES BUILDING AND SAFETY u copy thereof(Sec.3p800.Lab.Q) � �./ Poticy N ��7��Corllpany/N(..�����1�` - FOR APPLICANT TO FlLL IN -' ' �e ' �/' nl PY,� Y .. - �N� New Residential Bldgs.8 Poots EACH N0. .. FEE ADDnESS /! f J�I ��73+STG59TG ,�i�• ,❑.,Certitied co is here6 lurnished. �Certified copy is filed with'the county building inspection 1 8 2-Family,Sq.Ft.�// � — 5 LOCAIRY � Lf� "J�-+��� ,,�e f� nt."' � �: ' " MUlti-13mily$q.F}. NEAREST n Q M y/2��`�i ...�,�1'�/J� CROSS ST. � Y/„Y7�✓ �Date"/�Appiicant� /I "✓�L tL Residential Swimming Pools � � - owNEN OR � . . � � . ' . FI�7M N0.ME � G/�+ � '� CERTIFICATE OF EXEMPTION FROM WORKERS' � � � -' � MAiI n / - � -� .COMPENSATION INSURANCE . . Outlets:Rec—L'gh!_Sw._ � ADDRESS�� /7 �� � � - � �� First 20� �(This ssction need not be complated R the work Invdved by the CIT� �`�g� I.No�j/7J�{� permlt is for one hundred ddlars[$100)or lesa.) , Total No. Additional��- � PLAN CHECK � � .I certify that in the periormance of the work fo�which this permit • � � ,. qpp��ppM ' �is issued,1 shall not employ arry person in arry manner so as to -- -�-�� become sublect to fhe Workers'Compensation Laws.. . Lighting Fiztures . First 20 � ADDAESS � � - � � . . .. .. . . , . ' '� ' Total No. � Additional CITY �� � �� �- Tel.No. Date � �P���a^� � Rxed Appliances Not Over 1 HP NOTICE �TO APPLICANT: If,,aNer.making this Certificate of PERMiT /��j��.�G �.Exemption,you should become subject to the Workers'Compensatbn RangC_HeatCr_DW. _ A7PLIGANT /�� provisions of ihe La6or Code,you must forihwith comply with such Oven_Dryer_W.M._ A�DRESS .�� � ���� .provisions or this permit shall be deemed revoked. ,.,,. - .. Top._FAU _ VJH._ � � CIT ��,v 9,�v�- � 5�i�y�i Tel.Na. , LICENSED CONTRACTORS DECLARATION..., Hood_Fan _ Other_ I hereby affirm that I am licensed under provisions oi_Chapter 9 , LICENSEOR ,p�-�p (commencirg with Sedion 7000)of Division 3 of Ihe Business and Pisp.�—RoOm AiI Cond. _ REG.NUMBER' �vO�'- CIa59.0�O Prafessions Code,antl my license Is in tu0 fo�ce and effec[. paNer Apparatus 8 Wr9e App�iances DiSTetCT NO. , Pf�ocesseo Bv � y'/T� R Size 8 Type HP,KW,KVA,or KVAR �O 0.`d'n '� O C /��d� Lic.Class �a ' "- "Up to 1 Incl. - � �� � FlNAL - �� � LicenseNumber -. .. - .-.-.... ..-. . . -. - :.� y Over 1 to t0lncl. DATE � �"Contractor���"�l�� Oate � - - - - � �� .. y�3/�� . . , VALIDATION � Over 10 to SO lncl.� U FINAL ❑ I am exempt under Sec. . Over 50 to 100 Inc. gy. _ ... . .__ . _ _ W _... . o�er,00 a� . 6.8P.C.for this reason fA . - ServiCes,Swbd.,MCC 8 Paneiboards-- - � � �- � ---�-- �--- -�- -- - �:� 7�G A� Z . __ _ . _ . . Date: - . . . 0-200 Amp.Under 600 V Signalure � -�- 201-f000 Amp.UnAer 600 V�� � -�� �� ��-�� � � � �� " ��° °� .. .... ...... . .-_ .... .... .. . . Over f000 Amp.or Over 60D V � ...❑ ExemPtbn for Reg.Maint Elect. - - . ..._. - . _ . . .. . _._.__. _ .._ .. .. . ... ..� ° ��[.5..�! .. -' �-' � ' �� SINGIE FAMILY� � ��- � Temp.Power Pole 8 Appurtenances � • �+ e(;?,�7L'.� HOMEONMER-BUILDEfiDECLARATION � � �� � - � � �� ��� � ��� �� ��� ������� ���� �� I here allirm that I am exem t from the Contractor's License Law Sign with One Branch Circuit nv a �;9�n-Rg �r;ho id,la,ving reason�Section 7031.5,Busir�zss and fTc`zssions Additional Sinn 8ranch Circuits ., _ _. ,_ ._. _ . _ . _ _ -_ . Code): � - Misc Conduits&Conductors-. .-. . . . . ... _. . . -. ..... _. . . . .. . .- ❑ 1,as owner of ihe property,witl do the work and the s[ructure Other ISee Compie[e Fee Schedule)_ i9 not in[ended or ottered for saie(SecFion 7044,Business , . and Professions Code). --� - � - �� - - - - �-- � � - - _ _ _ _ .. . . _ . . _� _ __ .. _ . .... . CONSTRUCTION LENDING AGENCY � � ��-� � � �� �� � �- --� � � � � I hereby atfirm that there is a construMion lendirg agency for the n � performance ol lhe vrork for which this permit is issued(Sec.3097. .. pERMff FEE � -� � � -- - � (�b-Total) -� �� - �-- �- � ---� --- - �- -��--- - �� --� Civ.C.�. � ' - - -PLAN CHECKING FEE ..- . . ' .. _. . . . . . . .. . . . . ' Lender'S Name �O , . � . .. PERMIT ISSUING FEE ._ .., , ..,., Lender's Address �-- ..._ . ...--- --�--._. ._ .. . -.. I certify tha[I haoe read lhis application antl state ihat the above ,_ TOTAL FEE . ���9 _ ' _ '.. . ._ .. . . _ _. _ . _ ....__.. � information is correct.I aqree to tomply with all County ordinances and State laws regulating Electrical winng,and hereby authorize � � representatives of Ihis County to enter upon the above-mentioned � - � ��� - �� ��"� ��� - � '�� -'� ' � - - � � � � �� �� � � � � propert r inspection purposes. SEE REVERSE FOR EXPLANATORY LANGUAGE . . . � . /y►�...�12� �1�� _ Signature of Permiltee pate - - � � � _ . .. -r.t. " �, � r-"� ' , i ' . . , �i.i�. . _.., ,., � •--- i.. __ ."..•' .�� ' ' � ��.....' ' "'_._'_' __._ � I' I I` ' I I �,'^I � � I•�f � � � ' �';� I � �' I� � I ;`. I t � - ; i . � �, I� � i � I � r,;. `� � !i' , ; -. I ! - ' i ,f I �'� ' - � _ I� I � ' 1 ' ,.�. �• ���. I�i i,'r;J ; -1 . '_ . .- ; i'` i � ;;: ( .� �;, � , . ,_. � j� '� j'- z T c v�'�, "{,`'� c -i '�' ! r': `,� ' . o z -� o ,D o ' m ; !,- _ `o � '� _ c . i. 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