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' � • WORKER$'COMPENSATION DECIARATION -76a663 �o�a; �.'�APPLICATION FOR ELECTRICAL� PERMIT � � � �� "I hereby affirm rhatl have-a certificate oi consent io self �E'� . . . ins�re,or a cer�iflca�e of Workers'Compensotion Insuronce, COUNTY OF LOS ANGELES BUILDING AND SAFETY � , or a cerld�ed copy thereof(Sec.3800,l�.C.) �-. � � � - - s.�::? � - P❑oli'ty No "'" -�'`�Company '�"' _ ... .,. -' ' �. FOR APPl1CAM TO Fltt IN. . . . JOB . .. . . .. . � . Certified copy is hereby fumished. � New Residentiol Bldgs.�8 Pools � � EACH NO. FEE ADDREu - '�,� a . - 1 8 Z-Famil Ff. � . _ .Y. E — s � � LOCALIN . . . Certified copy is filed with Ihe caunty 6uilding inspec- � Y•�' NEAREST . tion deporimenl. , Multi-fomily$q.R. — � _ . � . .. .. CRO55 SL� �_... , � � � . � Residential Swimming Pools . . OWNER OR I. � Date'.. .. .. Applicont " , � � - . . � FIRM NAME � � . . � � . . � � � CERTIFICATE OF EXEMPTION FROM WORKERS � � � - ��- fl� � � � ` � � � '� • COMPENSATION INSURANCE � O�Heir.�RecT_light_Sw._ �v AppRESS .. ���+ . . Thb sMfoo n�ed no1 b�com IN�d N th�work(nyolved b � �r Fint 20� � � �� -� ( P � Y Tolal No Addilionol � �r ' - CITY�" .�. . � � Tel.No. �� tha parmlf Is lor on�hvndrad dollon(SI00J or las�.) . � . . . . . . . . - . ... I certify that in Ihe performante of the work for which this � - �� � ��pMK � � � � - permit is issued,1 shall nor employ any person in any manner � � . . � � . � . � � so as to become subject to the Workers'Compensotion lows. L19hling Fixtures First 20 � ADORE55�� � - � - . . � � � � Total No. � Additional � .. . CITY� Tel.No. Date � epplicant Fixed Appliances Not Over 1 HP � pp��t -� . �NOTICE TO APPUCANT: If, aNer making ihis Certiiicaia of � . APPtiCANT'�' � " � � � �Exemption, you should become subject ro ihe Workers' Range_Heater_D.W._ . ,_ , . � Compensotion provisions of fhe Lebor Code,you must forth- Oven _Oryer _W.M.— � ADORESS��� . - � . wi�h tomply wi�h such provisions or this permit shall be Top _FAU —W.H.— - deemed revoked. � � �� CITY ,' .- . Tel.No:��.�• .�� LICENSED CONTRACTORS DECLARATION Hood _Fon _Olher_� _ • ' - Disp. _Room Air Cond. — R GNN MBER � Clau. - �I hereby affirm thof 1 om licensed under provisians of Chopter 9 - � � � } . (mmmencing with SeUion 7000)of Division 3 of Ihe Business � � DISiRICT NO. �� . ` PROCESSED BY , a � �and ProfessionsCode,and my license is in fuli force and effecl. PO'''�er ApparaWs 8 Lorge Applionces . . - O , � � Size 8 Type HP,KW,�KVA,or KVAR� � . �'!�� � � � V , License Number"�'. . - lic.Closs � _. Up ta 1 Ind. � FINAL . - � . �- � , . . . . . . Over 1 lo 101nc1. DA�� ��_� �g VALIDATION--� � LL - Comractor - ,' . . Date'.. . , Over 10 to SO IncL '.. .. � � . ❑ .. � � . . . FINAL . . . � I am eaempt under Sec. Over 50 b 100 Inc. BY �, Q Over 100 � � � B.BP.C.for ihis reason ��� �n c . � � � � � � . . Date: Services.Sw6d.,MCC 8 Panel6oards � � � � . a � � � � 0-200 Amp.Under 600 V . . . . � . . � � w - � Signature � 201-1000 Amp.Undar 600 V - �� . � � � - �. f' � � D . � . .. � Over 1000 Amp.or Over 60p V . . - � . Exemplion for Reg.Maint.Elett. ; � � � $INGLE FAMILY � � Temp.Power Pole 8 Appurtenances� - � � . � � - . � � �� � HOME OWNER-BUILDER DECIARATION � Sign with One Branch Circui� �� '� � � �.� I.hereby affirm thol l om exempl from Ihe Conlroclor's License Additional Sign Branth Cirwits � � ' � M1�� f�1.� . - law for.ihe dollowing reason(Section 7031.5,Business ond , � � � . i1���(� � � Professions Code: � �� - �� �- � .�. . '. . Misc.Conduits 8 Coaduc�ors � .. . . . . . ��~� ���" � , .. �I,as owoer of�he property,will do�he work and the �� � r � -�slructure is nol inlended or offered for sale.(Seclion 01her(Sae Complete Fee Schedule)_ . . � � •.��� ��K! � 7044,8usiness and Prafessions Code). - ► .. f i . . . . . . . . . . . e,������i��%i.�?1 . ��CONSiRUCTION IENDiNG AGENCY � � � . . . . � " � �I hereby affirm ihal Ibere is a construdioo lending agency for � �;����� ��`��_ � Ihe performonce of Ihe work for which this permil is issued PERMIT FEE �(Su6•To�al) . . �� . , � (Set.3097,Civ.C.). . . . . . - . . . . � . . . . � � PIAN CHECKING FEE � � � � � . - � . � . - �. �lender's Name � . � � � .. . � � . � � � .. � � - . � . PERMIT ISSUING FEE � � ' " � � � � . � -Lender's Address � ' - � - �. � . - . . . - . I cer�ify that I have read this application and stote ibot the TOTAL FEE � � . � � . '_�.�� . - . . . I��-' abave infamation is correcl.I agree to comply with all Counfy . . . . _ ., . ._,.- • , � � � �. ordinances and State laws regolatinq Eledriml wiring,and . � � � . -'- .�� ' . � � � � � hereby authorize representotives of ihis Counry to enter upon _ � � � - � � �� � H;� ' . . � � � .- - the above-menfioned properry for inspeUion purposes. , SEE REVERSE FOR EXPLANATORY LANGUAGE 4� . SignoNre of Perminee. - � -� Date, : - � , . . � ..� . . . . . . � . . I - -� � I -. _' ' �c;r-� i- - - c ^-1 . - - � - c - - ; f , � r �' - �, - _: - r �.-' �-- . ' .. c - � , i = I . C 7 t� � 1. ` I.. .. � � t� U . r . ` 7 i _ .' I . _ . C - , , J . ` , i (` I _ , > ` _ C ��� ' C ' . i'" F ' ! • , �I -' ' 7 (�� 'C .. ._ ' _. � 1 ,,. — _ �_ `'- — (l . I - i_-' I ,.. ' � _ _ 'J � C ' j- ! � � " I � ' - � a� -- ! I - I � i�� � ` , . . � � i � �. � � , i � � � _ �. � . . < m I � " � � i � — - � � < � - . II - ; : ' i %i j i _ _ -. 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