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1170A 1171A (5)
WORKERS'COMPENSATIONDECLARATION �� '76a663 APPLICATION FOR ELE�TRICAL PERMIT . � � � � CE-906G 12�80) 1 hereby attirm that [ ha�e a certificate ot consent to se�e � COUNTY OF LOS ANGELES BUILpING AND SAFETY insure,or a certiflcate of Workers'ComDensation Insurance,or � - . ' a certified copy thereof(Sec.3800,La6.C.) � � � I Yolicy No. Company FOR APPLICANTTO FILL IN � D�HESS �3�SS �� lJ�/AI(7S � � � New Residential Bldgs.&Pools . EACH NO. FEE . � Certified copy is hereby fumished. 7&2•Family,5q.Ft. S — S LOCALITY OfAMDAt67 8a2 Multi•family Sq.Ft. NROSS STQAMONL� 'DA/t. BLf!"� � Certified copy is filed with the county building inspection � department. , � Residential5wimmingPools . OWNEfiOR �iw GOMM(§�Lvff+l. 9� ,��f, ' ."',1 fIPM•NAME TDJZ(T� �We�+A • Date Appiicant Outlets:Rec.�Light Sw,_L �7S �j ���4�MAIL� i ,�n� �t�st 2o AODRESS T.7D 9.GJAMAIlO �,HGYD CERTIFICATE OF EXEMPTION FROM WORKERS' Total No.� Additional '� � CITY QR�gi/}f� Tel No. � } . COMPENSAT[ON INSURANCE ' � PLqN CHECK n' � APPLICANT Q � � (This section need not be completed if the work involved � � , „f �{j /s U by the permit is for one hundred doilsre (SI00)oc less.) �'9nting Fixtures First 20 AOOHESS. �� � � � Total No,3L �ditional 0 i f certify that�in the performance of the wnrk for which ihls Fixed Appliances Not Over 1 HP � CITY � Tal No. U permit is issued.I sha11 not employ any person in any manner � vERMi7 � W ' �so as to become subject to ihe Workers'Compensatloe Laws. Range_Heater D.W._ � AVP 1 ANT �.. Z� OC a � Oven lDryef_W,M. � ADDRESS N � .�, �,/� Top _FAU �.,W.H.� ��L C e `F fi Z Date�[.�[�J\yplicant CITY �t//rLN� 7eINo. s'=�—� "/ -/ Hood_Fan �.Other_ p NOTICE 70 APPLICANT:If.efter making this CertiCcete of DisD. _Roam Ai�Cond� '� O LICENSE OR ; Exemption, you should become suHject to the Workers' REG.NUMBEP��'d � Cln+ i Compensation provisions of the Labor Code,you muat forth- Ppwe�Apperotus&Large Appliances DISTRICT NO. PROCESSED BY � with comply with such provisions or this permit shail be � • �� deemed revoked. ' � – Size&TYpe HP,KW,KVA,or KVA (� ' . � ' Up to.7 Incl. • ' � OVef 1 to 70 InCI. OATEL � � LICENSF.D CONTRACTORS DECLARATION ' Ovet 10 to 50 Incl. � VALIDATION I hereby affrtm that 1'am licensed under provislons of Chapter Over 50 to 100 Inc. � FINAL ... � - BY 9(commenting with Section 7000)of Division 3 of the Buai- pver 100 � � � � ness and Prohsdons Code,end my license is In full force and effect.� Services �� � � � ' . � � � � License Number Lia Class-j,7� a200 Amp,Under 600 V , , 201•1000 Amp.Under 600 V�p � Contnctor_Q��I�� Date Over 1000 Amp.or Over 600 V � � . , .. HOME OWNER-BUILDER DECLARAT[ON Temp.Power Pole&Appurtenances� � � . , J� I here6y affum that I am exempt from the Contractor'a Sign with One Branch Circuit (p , ' �� � 7,�p / License Law for the fnllowing reaaon (Se.ctinn 70J1.5,Busl- �ditional Sign Brauh Circuits � . .. . . . � � � � �� . � ness and Profasions Code): � � . #� z ,_, � � Miu.Conduits&Conductore I •[g Q�� � I, as owner of the property,will do the work and the p�her(See Complete Fee Schedulel— l � � structure is not intended or offered tor saie (Section , � • •2 9�,Q d� 7040,Business and Professions Code).. � � � CONSTRUCTION LENDfNG A(;ENCY � 0��(��j,.�^�� ' 1 hereby affirm that there is a construction lending agency �"�- � � - ; � for the performance ot tM1e work for which this permit is pERMIT FEE � (Sub-TotaD . - �,���•t• • ��9 . � issued(Sec.3097,Civ.C.J. � - � - ' � �� ' � LendePs Name PLAN CHECKING FEE (One•Founh Permit Fee) � . . �� • '6 9�$$ � � Lender's Address � PERMIT ISSUING FEE l0 � •• •6 9�a c=.�� � � I certity that 1 have rcad this applicaUon and state that the TOTAL FEE - �$ y�} � 0 7,0 8�II� � above informotion is corrcc4 I agree to comply with atl County ' '� � , �ordinances and State laa�s regulating Electrical wiring, and � � i hereby aulhorize representatives ot Ihis County to enter upon � � ' � � � � 'the above-mentioned wperty for Inspec�ion Durposes. 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