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0630A (4)
.NORKERS'COMPENSATIONDECLARATION 76A883 ���81 APPLICATION FOR ELECTRICAL PERMIT y I ,m that I have a certilicate ol consent to setf insura, CE-so6c � �te ot tvorkers'compensation tnsurance,or a cert�tied COUNTY OF LOS ANGELES BUILDING AND SAFETY Lj �1(Sec.3800.Lab.C.) �. ' � Comparry � FOR APPLICANT TO FllL IH �B (� ' EACH . NO. FEE �D�7ESS - 5„ ied copy is hereby(urnished. . New Residential Bldgs.8 Pools '- LOCALITY a��(O �j�'� d ied'copy is filed with'the�county'building inspeclion 1&2-Family,Sq.Ft. � — � 'Mulfi-12mily Sq.FI. — NEAREST O/�..y� ����/1rf mit tment. ' � ' � . - � CRQSS SL «'��� 'w ��� � Applicant � Residen!ial Swimming Pools � ptyt+Eq Oq ^n /], ��..� 1f.�e .,. . .. FIRMNAME 6�6'`��� �// s 'IFICATE OF EXEMPTION FROM WORKERS' p�p�s:Rec�Llght�Sw.� I MA� /�,� -ifh � COMPENSATION INSURANCE . � �D noo�ess � /��"�'�[/ � s n need not be completed if the work Invdved by Ihe Firsl 20- � Total No.� Addd'wnat . CITY�+ � ��I.No. �3 �� r one hundred dollars(57D0)w less.) . F•LAN CHECK rli7 L ' �in the performance o1 ihe work lor which his permit - qp�i�qM /�/ T ,ny sha�l rat employ arry person in man r to /�y'/�L �d to t Workers'Com L'ghting Fixtures First 20 � � ADDRESS !rT . th� r3 87 rota�No. � Additional CITY Q � C�T�.�a�'� � Applica Fixed Appliznces Not Over 1 HP S . � pPLICANT: If, er makirg lhis Cer�ifieate ol PERMii Range_Heafcr_ D.W. _ '°���M ;� ou should become subject to the Nbrkers Compensation . . . � d Ihe Labo�Code,you must lorthwith comply with suCh Oven_Oryer_W.M._ A�DRESS/'� �� this permit shall be deemed revoked. Top ._FAU.._.W.H._ � - CITY C�� ` Tel.Na 3� �o� JGENSED CO�JTRACTORS DECLMATION . Hood_Fan _Other_ LICENSE OR �hat rm ihat I am licensed under provisions oI Chapter 9 - �Disp:— Roan Air Cond. _ �EG.NUnreen aass. �with Section 7000)of Oivision 3 of the Business and AdB,e�d`Rry licen5e i5 in(ull fOrcE and Ef}PGf. pOw2r App3f3tu5&La�ge ApplianCes _ DISTRICT NO. PROCESSED BY ��� � � /� Si1e&Type HP,KW,KVA,or KVAR 'O O ic.Class -� Up�to 1 Incl. FINAI. ( �� �I � Over 1 t0 101nc1, DATE �— �i�/ yAUDATION 0 // / ' �ate�'�—z Over 70 to 50 Incl. U FINAL xempt ander Sec. _ - Over 50 ta 1001nc. BY . --- - - -- a :.for this reason Over 100 � � �Services;Swbd.,MCC&Panelboards . . . .. .. . , ._.- . . . ._ . . -�- Z DLte:� "" 0-200 Amp.Under 600 V � �� - -201-1000-Amp.Urider 600 V" � ' � �-� � - '�� �� � � � - - �� - �- � Over 1000 Amp.or Ovet 600 V �tion for Reg.A7aint.EIecL �- � " � --� SINGLE FAMILY - Temp.Power Pole 8 Appurtenantes . . .. i0ti".E OWNER-BLIILDER DECLARATION Sign with One Branch Circuit � T�h3I I 8til Cr2T01 flDm fhC COfIfIZCMIS LKB�SE L2W Artrlitinnnl Sinn Rranch Circuits - ��-- - � - � � ing reason I��tion i037S,ousl�ross arni Pru{essions . - , . M�sa co���i5 s c�a��mrs -�0 6 3 0 A . vner of the property,will do the vrork and the structure � ?ntended or offered for sale(Sectbn 7044,Business Other�See Complete Fee Schedule)_ ► #� � � � �2 � �fessions Cotle). CONSTRUCTION LENDING AGENCY � ' � � � - - �"� � � 8'7 5 - ' n that there is a construdion Icndirg agency for the • • • � �']5� � >f the work for which this permit is issued ISec.3097, pERMIT FEE � � - � - (Sub-Totaq � � - . Ofl13-87 ' PLAN CHECKING FEE � � - � - - PERMIT ISSUING FEE - . - Q �'� -� - �� =ss ' 'have read this application and state that the a6ove TOTAL FEE • � .�g � . . _ _ . ... . . � car ct.I a9ree to com0 ith all County ordinances egulatin EleCtric ring,and hereby aulMrize of th' ounty to er upon the above-mentioned �;��'�,sCe purpo5e SEE REVERSE FOR EXPLANATORY LANGUAGE -- ;��`,� � !�g J •=rmrttee a�e � - -"�� .. .. _ �. r. � �\ � � - - `- �-( I —I;r,� - --��'�—•I_i�•-•—_.�i ;� _ , r, , I �j''. . � ; i \ �l •I ' � i � � � � '�" - � ^ '���� I!"! 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