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1283A (6)
'NORKERS COMPENSATION DECLARATION i6A663 l0/87 APPLICATION FOR ELECTRICA-L�PERMIT I hereby affirm that I.have a certifimfe-of�consent to�self CE-806G insure,or a cerrificare of Worke.s Compensat�o��nsuran�e, COUNTY OF LO$ANGELES BUILbING AND SAFETY or a ceriified mpy ihereof(Sec.380Q Loh.-C.) - � . . � . � � P❑ol�icy No. � Company - - . _ _ - FOR APPLICANT TO FILI IN' � � .10B � ,r� - � Cert-fied copy is hereby furmshed. . NeW Residenfial Bldgs.&Po Is EACH � NO: . � FEE /+DDRE55 sF -�C3 �yg �� Certified co � 1$2-Famil S Ft- LOCALITY ' $i py s filed with ihe coumy building inspeo- Y 4• �'1 $ — � �'� NEAREST ���p � tion department - . . �- - -- � Multi-familySq.-Ft . CROSs SL P! �'t �y�+. y - Residenfial Swimming Pools � OWNER OR � Daie Applicqnt � � � � � � � - � FIRM NAME CERTIFICATE 6F EXEMPTION FRQM WORKERS' - �� �' ��MAIL � . .- . Ou}lets:Rec�lighl._ Sw. � � COMPENSATION INSURANCE -� �. � . �j ADDRE55 � �y�—� � F�rsf 20� � (This;ecfion need not be�complefed if�he work involSed�by Total No.� Addifional � CIN � _ :T Tel.No. -�/ �'� _ fhe permit is for.ane hundred dollors($100)or less�.)� � � �p�qN cHECK �� I cerfify that in ihe perforrtiahce of the�Work for which this . - - qpPLICANi - tf � ! permii is issued,I sholl nofemploy any person in any mtlnner - � � - - . � so ds to become subject to ihe Workars'Compensa�ion Lows. Lighting FixYures Firsf 20 ADDRESS ¢p - ' - - Total No: - -Additional . . ��. CITY � f p Tel:No. ( Doie ' � Applicant` - �-- Fixed Appliances Not Over 1 MP . � � PERMIT � NOTICE TO APPLICAN7:-If,�afier making ih's Ce�tificate of APPLICnM � ��,"�! - � Exemption, you�should $ecome�subject�to tFe-�Workers' Range�Heater_D.W._ � - . Compensation provisians of the Labor Code,you�musf-forfh- - - Oven _Dryer _W.M.— �� ADDRE55 � ( �'��y wiih comply with such provisions-or�ihis permii shall be Top —FAU _-W.H.— � � �..deemed revoked.- - . � - QTY '� � - . �Tel.No."j� LICENSED CONTRACTORS-0ECLARATION . . Hood _Fan _Ofher_ � ��� � - Dis —Roam Air Cond. — -LICENSE OR I hereby oifirm�haf I am licensed und�r provisions of Chapter 9 .�P� � . . REG.NUMBER ��� : ��a�- Class. . (commencing with Secfion 7000)of Division 3 of 9he Business � � � DISTRICT NO, PROCESSE BY and Professions Code,and my license is in full-force and effect Power Apparafus&Lprge Applionces 9� - � . � . .- Size&Type HP,�KW�,KVA,or�KVAR� - r�`P ¢C.i.c��' � � License N�mber � Lic.Class Up ta 1 Incl: � � �/ � FINAL CoNraciar � Date � - �Over 1�0 10�Incl. . DATE ��y°', C%J�.,y yqpDATION � � t� G� d . ❑ . � � Over 10 fo 50 Ind. �� ' FlNAL i� � I am exempt under Sec. � Over 50 to lOp Ino BY � t � � 8.8P.C.for�his reason � Over 10D � ��� t9 ' - . � . . Serdices,Swbd.,MCC&Panelboards � � . - �- � I Date: 0-'200 Amp.Under 600 V � - . Signature� 201-IOOD Amp.Under 600 V � � � ❑ Over 1000 Amp.or Over 600 V - , Exemptiomfor Reg.Moint.Elect. � SINGLE FAMILY � � - Temp.Powe�Pole�&Appurtenances � - HOME OWNER-BUILDER DECLARATION� Sign.wifh-0ne 8ronch Circuit. � � / - I hereby affirm ihaf I am exempt from ihe Conlrotlor's License Additional Sign Branch Cirwits � Law for the following repson (Sedion 7031.5,�Business ond � . . � � � ?� ��,��R� �,Pro ssions Code): � � - as owner ot the en � M;sc.Cond.uits&Conduciors � 74.�� ° �' °'G^' , prop y,will do the-work and the Other See�Com lete Fee Schedule_ � �trudure is no� intended or offered for sale (Section ( . P ) , ,.'� �,�� (�5��� 7044,Business and Professions Code). � + � � � CONSTRUCiION IENDING AGENCY . . . � - ` �' I W,:%.G i I hereby affirm fiat there is a mnsiruction lending agenty for ihe performance of ihe work forwbich fhis permit is issued PERMIT FEE � - (Su6-Tofal) (�7�.p1 �i�� �""'�S 4 (Sec.3097;Civ.C.): � � � � � . � � - � ��� - � � � - PLAN CHECKING PEE � �- � � - . , Lender's Name ' �- � � - - � . � . PERMIT.ISSUING FEE . . �'!.� �� . Lender's Address - � � . I certify thot�I have read�ihis applimtian and sfate ihat��he TOTAL FEE . � � l' �� � above informotion is correci.I agree fo mmply wifh oll County � - � � � � ordinances and�Stale laws regula�ing Elecirical wiring,.and . � . . . . � hereh i authoriza represenfatives of this County to enfer upon - � - � fhe�y��ve-mentiened-proper fo�.inspeetfon purposes. � � � � - / p�,/��� �2-�� -SEE REVERSE FOR EXPLANATORY LANGUAGE _� I `t}"� ��d ,_ `_°��"V�1.— _ . . . . _ . _ _ . __ _ . — ---� - Sig fu fPerrr�itfee - � ---- 6ate f-- -� - �-- . . �� _.----- �------ __._ � c .:-e -o y.v �:n � tfp I �n.�4 y�� �� 5'_� �n O�G � �Q � � C �o.Z7 � � ' - - � �� -- . \rUj Q � O u0D D � �y L` �i m S'j � p � 'n p'� q!� � � . �°'` >..�Cy� = C e°g�n�..� 0 �3 it 6 � � � � ' - o c `c'v e'� c c-gs� � 3 �1 'a -� �-c � ,� � v ° � � ��� cr ss c ar > c�m� ° � � a ��s,-� � � w 'y- � o c e�:«` s � �,s �.c £ � �3 ��� � j � �c qy E°�� a � m � � � �� � ° , � � E � ,'�'. 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