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� � NOPKERS COMPENSATION DECLARATION 76A663 10/61 APPLItATIfJN FOR Ei.ECTRICAL PERMIT - � I hereby aff fhpf I lio e a ce f f ai �of mnsenf to self CE-606G . � r�s�re, o a ce t fic re of Vdorkers Comp nsatiop In:urance, _ _ COUNTY OF LOS ANGELES BUILDING AND SAFETY � or c cerhfied copy ihereof(Sec.3800,Lab.�C.) � . . P❑olity.N �..c �Y'� CoYpany= '.� ���� ' NewRes ... , FORAPPLICANTTOFILLIN--- . -..� ..-JOB :... -a .�..� .� .�..�. . Ce r�fled co s hereb furn�sh�ed�.�� EqcH No. �FEE aooREss �`� � -;r�- - -. �? �_ _� identiol Btdgs.&Pools — - Certified-copy s fi(ed-with the county buildmg-inspec- 7&7-Family,Sq.Ft.��. �- — S LOCAL�TY �' tion depdrtmenf � Mulh-family Sq.R._ NEAREST f ,�r�.. ����� . CRO55 ST. /___,��>�}'" � Residential Sw mmmg Poals � �� Dote__�r-=AppljCant L - �, - � � OWNER OR � � ,.r-� FIRM NAME � P C`� � CERTIFICATE OF EXEMPT40N FROM.WORKERS' - putlets�Rec�1 ght�-..�.$w,� � ��'w'�� �- - -�OMPENSATION INSURANCE ----- � �nooReSS �� � Firsi 20 , (This ssction need�nof be iomplefed if 1he work involyed hy Totol No. .Additional - CITY - Tel.No. � the permit is-for one hundred dollars(5100)or�less.)� --� � �DtnN cHECK - � � - � I cenify�hnt in�the performance of the-work�or whi<h ihis , � qppLICANT ' permit is-issued,I shafl nof employ qny person in any manner � . � so as to become subject fo tha Workers'Compensation-�Laws.� Lighting fixiures - First 20 A�ORESS - ' � . � . . . � Additional � � ' Total No. � CITV � Tel.No. . Dafe Applican� � � �`-� - Fi.xed Appliances Nof Over}.HP PERMIF N0710E TO.APPLICANT� If ofter making this Certficate of �� � APPLICANT-- ��� � fJ � j Exemption, you�should become�subject fo ihe.�Workers' Range,_Heater;D.W.— � Compensafion piovisions of�the Laboi Cbde,you mosi 4arlh- � Oven —Dryer �W.M.— - � ADDRESS. sj � f��"'-��.+ - � with-comply "th such�provisions��or�fhis-pennit shall be �Top� —FAU _.W.H.— � - � deemed revoked.- �. ' � . �S�/ �����'� � Hoad _Fan _,_.Other_ CITY Tel.No. .LICENSED CONTRACTORS DECLARATION - � LICeNSE R i-�" i I hereoy affirm fhot I am licensed under provisions of�Chapfer 9 Disp,. �—Roam A r-Cond. — REG.NUMBER �t� �s'� G�ass. '��- (commenc n�with Section 7000) f Divisioh 3 of the Business - � DISTRICT NO. � � PROCESSED BY and Professions Cade,and my license is infull force and effecl. Power Apparatu3 8 large Appliances , �(� � � - .a . .�.. �F� �� Size&Type HP,KW,KVA,or KVAR� � �C.�,`_,^�..00t..�_,�_ � �g � � �License Number���Lio Class�_ Up to 1�Incl. - FINAL � � � ,�1/� >�-�/,d ��aC�' . . Over 1 �u l0.lnd.. DATE i-�.1_"�J� VALIDATION � . � CoMracfor"'a"' f✓������ Dpfe . Over lO to 50 Incl, - � - �' ❑ FINAL } I am exempt under Sec. . Over 50 to 100 Inc. BY �6,�'�;� ( . � � � �. � - � Over 100� . - ���°'���`J . - � '�" . B.BP.C.Forthis reason� .,. ..� , � � � - � � Services,Swbd,MCC&.Ppnelboards ' � �Dore: 0-�200 Amp.Under-600 V �� Signafura � � � 20T-1000 Amp.lJnder 600 V - � Over 1000 Amp.or Over 50D V - � Exemp�ion for Reg.Moinf.Elect � � � . . . . . . - SINGLE FAMILY � � Temp.Power-Pole 8 Appurtenances � HOME OWNER-BUILDER-DECLARATION � S gn with One Branch Circuit � � I hereby affirm�thai I qm exempt from the Coniractor's License Additional Sign 8ranch�Circuits � Law for fhe following re6son(Secfion 7031.5, Business and . . v 1 C'j,!'A � Professions Cade): � � . . � �� � � . . : . . � ❑ I;os owner of ihe property,will do the work and the Miu.Canduits&Conductors � . 1�''� r:m :; a�� �. � structure is not iMended or offered�for sale (Sedion �Other(See Complete Fee Schedule)�_ � ' � . . . { ,,,. . � 7044,8usiness and Professions Code). . . i ° `'' � ''�' . � CONSTRUCTION LENDING-AGENCY - � � � . . ' ` `'' " +'�'�"���� I hereby affirm ihat ihere is a cansh�ction lending ogency for . - a�, � tbe erformance of the work far which this ermit is issued PERMIi FEE . . � r��''�`. V" - . P P . �(Sub-Tofal) . .. (Sec.3097,Civ.C.).�, � � . � � � � � , . � � � . . . PLANCHECKING�FEE���� � � �� - � . . . , Lender's Name � � �. � � � � /� � � � " � � . � PERMIT ISSUING FEE . .. . � � � � � ' Lender's Address � . � � I certify Ihai I have read this opplication and sto�e ihat the TOTAL PEE . _ � above information is correci.I agree�o comply with all County. � � . . ��ordinances and Sfcte laws regulating-Elecirical wiring,and- � . , - � hereby authorize representatives of ihis County to enter upon � � � � � . , � - � the} abov -meniioned praperry for nspection purposes. � SEE REVERSE FOR EXPLANATORY LANGUAGE �1�,,•�z��r'�yr�.g'��j G� ��t7s� - _ _ _. — __ - - _ _ __ ----_ __ Signature of Permitt�e - ------ Date .. � , . . . - .. _� -__`_ �_:., _._: ,;. ,.. .. ._ . ._.._. �_ :_.: �_,., -', ,_ ,_ .•'. :'.� ., :.�.� _..'_ __ -�' .. , . . .�: v' ,a5.�fa ,—�j, iV f�4,�.�y a'� � Q..=� .�� .s.�".U O ��� . ` {I �,4 - { � . � \�M$� O 8 �Q A � Ci.� . � � � h � �� '�^2 .. f I . � , , p 5 p en CA *� C� G � .x` '.C p � . C.0 . 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