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, WORKERS'COMPENSA710NDECLARATION 78A663 �o�e� qppLICATION FOR ELECTRICAL PERMIT � I hereby affrm that I have a certilicale ol consent to selt Insure, CE-806o w a certificate of Workers'Compensation insurance,or a certified COUNTY OF LOS ANGELES BUILDING AND SAFETY copy there/o'f�(�Sje]c.3nBO.O.Lab.C.) PoIiCy NO.��7O/Q�IL�'nmpy�y�NDUS/��/��C _ FOR APPLICANT TO FllL IN . . . .. ..- JOB - � `� D�. ❑ Certitied copy is here6y furnished. , . , I N�O• New ResideMiat Bldgs.8 Pooi� .�-�� J EACH NO. . FEE AD�RESS� �,� � Certilied bopy Is filed with ihB CWnty building inspedion �8 z-Family,Sq.Ft.�� �d — � LOCALITY ,!� 7 �jr�' y�ep4,trt�t,- ' -� Multi-lamily Sq.Ft. — NEAHEST .., .: ....; ^ /�jv��d � ' ' ����' �,� Residential Swimming Pools cno5s Sr. ,Q, Date APPIicaM -. .. Ov�'NE�or� /J � � � .. _ . . FIRM NAME/�/Z�T'YJ �tr � CERfIFICATE OF EXEMPTION FROM WORKERS' • i � n�ni� - COMPENSATION INSl1RANCE - � . Outlets:Rec—L'ght—Sw.— , _ . qoorseSS �/ � /L(.V �� �� ��TMa xctbn need not 6e completed il the work involved by the ' First 20 parmit ie for one hundred dollars(5100)M IeBs.). � TO�°�NO� Additional� � - �CIT ��� � e.No. I certity that in ihe perfo�mance ot lhe vrorklor which this�permit . . . wN CHeCK � �_ � : is Issued,I,Shall.not employ arry pefSOfl ir1 afry fn3flnCf 50 24 t0 -- -�' �� pP��CAM become subject to the Workers'Compensa�ion Laws. , - L'ghting Fixtmes Frst 20��-- - - �ADDRESS � -� � . . . .. , �; AddiCwnal � ' � .� - � � .: Total No. � CITY -���--�� -� ��� � Tel.Na. Date ��Ka^t - � Fixetl Appiiances Not Over 1 HP PE�Mii � . NOTICE TO APPLICANT: If, aFter making this Certificate of A�f�LicAM � •��'(' — -�i 4 � Exemption,you 5hould beCome Subject to the Workers Compensation , _ Range_Neater_ D W. _ � � .provisions of the La6or Code,you mus[forth+.ith comply wi;h such O��en_Dryer_ W.A1._ ADDRESS � �x ���� � ��� -provisions or this permit shail be deemed revoked� .�, . _ _Top __FAU _W.H._� , , p LICENSEO COMRACTORS DECLAF7ATION Hood_Fan _Othcr_ ��TY //1���/�7D��-Tel:N. 9��f���� , .I hereby.affirm that�l am licensed untler provisions of Chapter 9_..., LICENSEOR c 7 (commencing wilh Section 70�0)of Division 3 of the Business and -�"Oisp. _Room Air Contl.-_� qEG.nvMeeR ��6J -�--- �'s'�C�U . Professions Code,and my license is in full force and etfect. oisraicr No. eftoCESSEo er � , . Power Apparetus 8 Larc�e Appliances___ } . ..... .. /� �/�, O.! %(�[/Q� C�O _ Size&Type HP,KW,KVA,oi KVAR l � � � {��\O n•2 � License Number Lic.Class -... .. ._...UP to 7 Incl. .. _. .. . . '....... --"- � - FINAL �i. . . . . ... ..... .,,. �� OvEr 7 t0 t01nCl. �A�/��U-d'� VALIDATION � Contrector��tZ77z1-G/�_ Date'� - - 0 Over 10 to 50 Inci. FINAL ~ ❑ 1 am ezempt under Sec. � _ Over 5D to 700 Inc., gy � �W . .. . . . ... _ ._ - ._ ._ . _. B.BP.C.for this reason Over 100 � d.' N ' pa� - � -Services;Swbd.:MCC 8 Panelboards . .. . . - . S . .... . ... .. .. `, 7, G.n.-. Z --_ . . .__ _.. _ . . . . 0-200 Amp.Under fi00 V � Signature -� ��� 201-�7000 Amp.Under 600 V - - � -� - � -- - ❑ � - .. . . .. .. . ... . .. . ..Over 10�D Amp.or Over 600 V . . . . . . ... . . . �i i�i-s e o 2� . Exemption for Reg.Maint.Elect. . �--•-� �J.�'i C) - "��- -��� -� - -- �SINGLE FAMILY - -�-�� ' � Temp.Povrer Poie 8 Appurtenances HOME OWNEFi-BUILDER DECLARATION �-�- � �- ' - - - -- � � --- - " " " � �" �-� I hereby aflirm that I am ezempt fmm the Contractor's License Law Sign with One Branch Circuit �� - � �°-° � C��'��� for tha fonowirg reason(Section 7031.5,Business and Professions p==���-"-1 Sidn Brerh Cirai!s� ...... _.___ _ . ... ___ ..._ _. .,.,�G��_��.. C��): - ❑ I,as owner oF tha will do the vrork and the structure Misa Conduits 8 Conductors• � -- - � � - �-� - - � . �- P�rtY� . . ..... . is rat inleMed or offered fa sale(Section 7044,Business Other(See Complete Fee Schedule)_ , _ ... _ . . . . . ..__. .... _. . . . . . � ._ and Professions Code). � � �� - ���� CONSTRUCTION LENDING AGENCY -- -- --�- - � � - - �. I hereby affirm that there is a eonstrudion IeMing agency for the � performance of the work for which this permit is issued(Sec.3097, ..- pERMR FEE ----- - - � -- (Sub-Total) � . _ ... . .. .... ... ...... .. . Civ.C.). . PLAN CHECKING FEE .- .. ._.... . . _ .. • Lentler's Name ._ . . _... _ ._ _ . _._. .. ...._....- � - __ PERMR ISSUING FEE _ _.;., _ . , ,.�(, . � Lender's Address � I certify ihat I have read this appiication ard state that the abova __ TOTAI FEE /� � � ..._ . .. . .. ... ....... . .... . ... .... . _ . _.. . information Is correct.I agiee M comply wilh all County ordinances � � � ���� � � � �� . and State laws regulating Elec[rical wiring,and hereby authonze represeMative5 01 ihig County to enter upon the above-mentioned � ���� '�� � ' - '� � � --� �-" ���-- � . .. .. .... . . _ ...__...__ ._'.__..__... prop tor inspection purposes. � � .r [�Y�� � .. ...... ...SEE REYEflSE FOH EXPLANATORY LANGUAGE ._ ._. . . r ._.. .. _... _..._.._. .. .. 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